USING THE CIRCUMSTANCES OF SYMPTOM EXPERIENCE TO ASSESS THE SEVERITY OF URGENCY IN THE OVERACTIVE BLADDER

Neurogenic Lower Urinary Tract Symptoms, Fatigue, and Depression-Are There Correlations in Persons with Multiple Sclerosis?

The symptoms of multiple sclerosis (MS) frequently include fatigue, depression, and neurogenic lower urinary tract symptoms (LUTS), causing severe burdens on affected individuals. The relationships between these symptoms have not been intensively researched and there are no studies on the detailed influence of the different neurogenic LUTS. We aimed to investigate the relationships between fatigue, depression, and neurogenic LUTS as recorded in bladder diaries by persons with MS. We analyzed the bladder diaries of 274 people and their scores on the Fatigue Scale for Motor and Cognitive Functions and the Centre for Epidemiologic Studies Depression Scale (German version). The neurogenic LUTS were defined as urgency, reduced voided volume, increased standardized voiding frequency, nocturia, and urinary incontinence. Those suffering from incontinence, nocturia, reduced voided volume, or urgency had higher fatigue scores compared to those without these symptoms. Those with nocturia showed significantly higher scores for depression. The severity of urgency and voided volume had the greatest effect on the severity of individuals' fatigue and depression levels. With increasing urgency, the risk of clinically significant fatigue and depression was expected to increase. Urgency and voided volume correlated most with fatigue and depression. A prospective longitudinal study investigating fatigue/depression after the successful treatment of neurogenic LUTS is needed to clarify causality and offer possible treatment options for fatigue and depression.

Effects of repetitive functional magnetic stimulation in the sacral nerve in patients with neurogenic detrusor overactivity after suprasacral spinal cord injury: a study protocol for a randomized controlled trial

BACKGROUND

Neurogenic detrusor overactivity (NDO) is a serious and common complication after spinal cord injury, affecting patients' quality of life seriously. Therefore, we developed this research protocol to evaluate the efficacy of repetitive functional magnetic stimulation (rFMS) in the sacral nerve in patients with neurogenic detrusor overactivity (NDO) after suprasacral spinal cord injury (SCI) and provide more options for rFMS in treating NDO after suprasacral SCI.

METHODS

This study is a single-center, randomized, parallel-group clinical trial. We will recruit the patients with NDO after suprasacral SCI in the Rehabilitation Department of the Affiliated Hospital of Southwest Medical University from September 2022 to August 2023. They will be assigned to the rFMS group and the sham stimulation group randomly. The sample size is 66, with 33 patients in each group. The rFMS group will receive real rFMS treatment of the sacral nerve (100% stimulation intensity, 5 Hz, 20 min each time, five times a week), and the sham group will receive sham stimulation. Both groups will receive similar treatment strategies, including medication, standard urine management, acupuncture treatment, and health education. The bladder compliance (bladder capacity/detrusor pressure) and pudendal nerve electromyography will be evaluated at baseline, 8th week of treatment. The residual volume of the bladder and bladder diary will be recorded once a week during 8 weeks of treatments. SCI-QOL and NBSS will be evaluated at baseline, the 4th and 8th week of treatment. In addition, the above assessments will be followed up at 8 weeks after the end of treatment.

DISCUSSION

It is expected that the bladder function, symptoms, and quality of life might be significantly improved after rFMS of the sacral nerve.

TRIAL REGISTRATION

The China Clinical Trials Registry has approved this study, registration number: ChiCTR2100045148. Registered on April 7, 2021.

Neuroimaging of situational urgency and incontinence provoked by personal urgency cues

INTRODUCTION

Situational triggers for urinary urgency and incontinence (UUI) such as "latchkey incontinence" and running water are often reported clinically, but no current clinical tools exist to directly address symptoms of UUI provoked by environmental stimuli. Previously we have shown that urgency and leakage can be reproduced during urodynamic studies with exposure to personal urgency-related images. Here we investigate the neural signatures associated with such situational triggers to inform potential therapies for reducing reactivity to these personal urgency-related cues among women with situational UUI.

METHOD

We recruited 23 women with situational UUI who took photographs of their personal "urgency trigger" and "safe" situations and were exposed to them in a magnetic resonance imaging (MRI) scanner. We identified brain areas that were more active during urgency versus safe image exposure.

RESULTS

We found that, during urgency image exposure, main components of the attention network and decision-related processes, the middle and medial frontal gyri, were more active (p < 0.01). In addition, areas well known to be involved in the continence mechanism, such as the cingulate and parahippocampal areas, were also more active during urgency image exposure.

CONCLUSION

Exposure to personal situational urgency images activated different areas of the brain compared with safe environments, highlighting the complex brain mechanisms that provoke real-world urgency. Using brain and behavioral-based therapies which target the attentional areas identified here and extinguish cue reactivity might reduce symptom burden in this subset of UUI sufferers.

Organ cross-sensitization mechanisms in chronic diseases related to the genitourinary tract

There are various refractory chronic inflammatory diseases related to the genitourinary tract, such as interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome. It has been reported that in the general population, these diseases are related to other chronic illnesses, such as irritable bowel syndrome or vulvodynia. Herein, we review papers regarding pelvic organ cross-sensitization, a factor which is considered to contribute to these relationships. Several other researchers and ourselves have reported that noxious stimuli from a diseased pelvic organ are transmitted to an adjacent normal structure via shared sensory neural pathways at the prespinal, spinal, and supraspinal levels, resulting in functional changes in the adjacent normal structure. In conclusion, since there are few treatments to cure interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome completely, further studies regarding organ cross-sensitization may provide new insights into the pathophysiology and treatment strategies for these diseases.

Transient receptor potential channels in sensory mechanisms of the lower urinary tract

Disruptions to sensory pathways in the lower urinary tract commonly occur and can give rise to lower urinary tract symptoms (LUTS). The unmet clinical need for treatment of LUTS has stimulated research into the molecular mechanisms that underlie neuronal control of the bladder and transient receptor potential (TRP) channels have emerged as key regulators of the sensory processes that regulate bladder function. TRP channels function as molecular sensors in urothelial cells and afferent nerve fibres and can be considered the origin of bladder sensations. TRP channels in the lower urinary tract contribute to the generation of normal and abnormal bladder sensations through a variety of mechanisms, and have demonstrated potential as targets for the treatment of LUTS in functional disorders of the lower urinary tract.

Questionnaire survey assessing seasonal changes in lower urinary tract symptoms in men with benign prostate hyperplasia

OBJECTIVE

A prospective questionnaire survey was conducted for patients with benign prostatic hyperplasia (BPH) to clarify seasonal changes in the lower urinary tract symptoms (LUTS).

MATERIAL AND METHODS

Male patients receiving α1-adrenoreceptor antagonists for BPH were enrolled. They answered the International Prostate Symptom Score (IPSS) questionnaire, and an unvalidated questionnaire that consisted of 10 questions assessing variations in the urinary stream (voiding symptoms) and urinary frequency (storage symptoms), depending upon the seasons or the patients' subjective sensations of warm and cold in last one year.

RESULTS

A total of 412 participants answered IPSS and our unvalidated questionnaire. Of the 412 participants, 36.7% and 59.0% realized seasonal variations in urinary stream and frequency, respectively. Among patients perceiving seasonal urinary stream and urinary frequency changes (n=151 and n=243, respectively), significantly more patients realized weaker urinary stream, 59.8% (107/179) in winter compared with 26.2% (47/179) in summer, and increased urinary frequency, 69.8% (199/285) in winter compared with 20.7% (59/285) in summer (p<0.0001 and p<0.0001, respectively). Even in summer, when feeling cold, 34.7% and 56.3% realized a weaker urinary stream and an increased urinary frequency, and even in winter, when feeling warm, 53.4% and 69.4% realized a stronger urinary stream and a decreased urinary frequency. Those with seasonal stream changes showed a significantly higher IPSS total, voiding and post-voiding scores than those without, and those with seasonal frequency changes showed significantly higher IPSS total, storage, voiding, and post-voiding scores.

CONCLUSION

Our results revealed seasonal changes and feeling of hot and cold were associated with subjective changes of LUTS in BPH patients.

Reproducing situationally triggered urgency incontinence in a controlled environment

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.

Should we be revisiting LUT basic science and clinical measurement of LUT sensation to improve patient care? ICI-RS 2019

AIMS

This article reviews current knowledge of the underpinning mechanisms of how the bladder senses fullness locally and also revisits clinical measurements of lower urinary tract sensation. The former represents cellular sensing during bladder filling whereas the latter describes the sensations leading to conscious perception of bladder fullness.

METHODS

The topic was discussed in a "think tank" session at the 2019 International Consultation on Incontinence-Research Symposium in Bristol, UK; summarized in the present review.

RESULTS

Recent advances in the basic science of bladder sensing relating to (a) the bladder wall-urothelial cells, sensory nerves, interstitial cells, and smooth muscle cells and (b) putative chemo/mechanosensors in the urethra-paraneurons or "brush cells" are discussed. Validated clinical measurement of lower urinary tract sensation is reviewed in the context of how this could be better harnessed for patient benefit. We discuss the potential of app/tablet/mobile technology based on triggers and distractors to override aberrant local sensing/higher sensation and how these technologies could be utilized in treatment.

CONCLUSIONS

We conclude that a better understanding of bladder sensation is essential to inform clinical management of lower urinary tract symptoms.

TRPM8 channels: A review of distribution and clinical role

Ion channels are important therapeutic targets due to their plethoric involvement in physiological and pathological consequences. The transient receptor potential cation channel subfamily M member 8 (TRPM8) is a nonselective cation channel that controls Ca²⁺ homeostasis. It has been proposed to be the predominant thermoreceptor for cellular and behavioral responses to cold stimuli in the transient receptor potential (TRP) channel subfamilies and exploited so far to reach the clinical-stage of drug development. TRPM8 channels can be found in multiple organs and tissues, regulating several important processes such as cell proliferation, migration and apoptosis, inflammatory reactions, immunomodulatory effects, pain, and vascular muscle tension. The related disorders have been expanded to new fields ranging from cancer and migraine to dry eye disease, pruritus, irritable bowel syndrome (IBS), and chronic cough. This review is aimed to summarize the distribution of TRPM8 and disorders related to it from a clinical perspective, so as to broaden the scope of knowledge of researchers to conduct more studies on this subject.

Bladder sensations in male and female overactive bladder patients compared to healthy volunteers: a sensation-related bladder diary evaluation

Objectives: To investigate the differences in bladder sensations of overactive bladder (OAB) patients compared to healthy volunteers. In addition, to see if bladder sensations are different in men and women.Methods: In a prospective, longitudinal study (METC 09-2-095), 66 volunteers and 68 OAB patients were included. Anticholinergic medication was stopped. Subjects filled out a sensation-related bladder diary (SR-BD), for two periods of 3 days, including a 4-points urgency scale and visual analogue scale for perception of bladder fullness.Results: In total, 6160 voids were assessed. Patients voided more often with higher degrees of urge at a lower mean voided volume (193 vs 270 ml/void; p < 0.001) than healthy volunteers. The mean urinary frequency per litre diuresis was also higher (5.8 vs 4.1/l; p < 0.001) in patients. At the same voided volume: patients perceived a higher mean bladder fullness, independent of the degree of urge, and higher urgency (1.4 vs 0.5/100 ml; p < 0.001) than healthy volunteers. There were no gender differences in the above-mentioned voiding parameters, except for the mean voided volume at urge 3 in volunteers (340 ml in men vs 362 ml in women; p = 0.03) and urge 1 in patients (171 ml in men vs 135 ml in women; p = 0.027).Conclusions: Bladder sensations were significantly increased in everyday life for both male and female OAB patients compared to healthy volunteers. OAB patients experienced a higher mean bladder fullness sensation, independent of the degree of urge, and higher mean urge/urgency at the same voided volume than volunteers. Bladder sensations are crucial in the assessment of treatment response.

Somatic and psychological triggers for bladder storage symptoms among men and women

INTRODUCTION AND HYPOTHESIS

To determine the prevalence of somatic and psychological triggers for bladder storage symptoms among men and women who have not been diagnosed with overactive bladder (OAB) and to determine their impact on individuals' quality of life (QoL).

METHODS

Randomly selected male and female volunteers were screened for the presence of bladder storage symptoms and their impact on their QoL using the UDI-6 and IIQ-7 questionnaires. They were also asked about somatic and psychological triggers for these symptoms using the validated SOPSETO questionnaire. Individuals who had previously been diagnosed with or treated for OAB, prostatic hypertrophy, neurological disease or cancer were excluded.

RESULTS

Sixty-six women and 40 men were included. There was a significantly higher prevalence of urinary urgency (41% vs. 19%, p = 0.021), urge urinary incontinence (22% vs. 0%, p = 0.002) and stress urinary incontinence (30% vs. 3%, p = 0.001) among women than men. Total UDI-6 (17± 15 vs. 9± 8, p = 0.04) and IIQ-7 (21± 10 vs. 15± 4, p = 0.02) scores were also higher among women than men. Of the total 34 triggers evaluated, 18 were ranked significantly higher among women than among men. There was a good correlation between the SOPSETO and the UDI-6 and IIQ-7 scores primarily in women (r = 0.46, p < 0.0001; r = 0.69, p < 0.0001) but also in men (r = 0.44, p = 0.009; r = 0.39, p = 0.02).

CONCLUSIONS

Women who have not been diagnosed with OAB report bladder storage symptoms more frequently than men. Somatic and psychological triggers are more likely to stimulate these symptoms in women than in men and might add burden to their QoL.

Association of baseline severity of lower urinary tract symptoms with the success conservative therapy for urinary incontinence in women

INTRODUCTION AND HYPOTHESIS

To identify the association between the symptom severity and outcome of conservative management for OAB, SUI and MUI. Conservative treatments are recommended for overactive bladder (OAB), stress urinary incontinence (SUI) and mixed incontinence (MUI). It is unclear whether disease severity affects treatment outcome.

METHODS

Patients receiving conservative management were reviewed. Disease-specific questionnaires (OAB-q SF, ICIQ-UI SF) and bladder diaries recorded baseline symptoms. Success was defined by Patient Global Impression of Improvement questionnaire (PGI-I) response of "very much better" or "much better". Non-parametric statistical tests and logistic regression were used.

RESULTS

In 50 OAB patients success was associated with lower symptom severity [30 (0-80) vs. 80 (23-100), p = 0.0001], fewer urgency episodes [4 (0-12) vs. 6 (0-11), p = 0.032] and lower ICIQ-UI SF [5.5 (0-20) vs. 15 (0-21), p = 0.002], but higher QoL [67 (20-101) vs. 24 (6-58), p = 0.0001]. In 50 MUI patients, variables were fewer urgency episodes [3 (0-10) vs. 6 (0-16), p = 0.004] and lower ICIQ-UI [11 (1-18) vs. 15 (5-21), p = 0.03]. In 40 SUI patients, variables were fewer incontinence episodes [1 (0-4) vs. 2 (0-5), p = 0.05] and lower ICIQ-UI [11 (6-16) vs. 13.5 (11-19), p = 0.003]. Multiple regression confirmed OAB-q QoL [odds ratio (OR) 1.10 (95% confidence intervals 1.04, 1.1)] for OAB, urgency episodes [OR 0.74 (0.56, 0.98)] and ICIQ-UI [OR 0.83 (0.71, 0.98] for MUI and ICIQ-UI [OR 0.57 (0.40, 0.83)] for SUI.

CONCLUSIONS

Milder baseline disease severity was associated with successful outcome. There is potential for triage at initial assessment to second-line interventions for women unlikely to achieve success.

Recalcitrant chronic bladder pain and recurrent cystitis but negative urinalysis: What should we do?

Purpose

Lower urinary tract symptoms (LUTS) may be associated with chronic urinary tract infection (UTI) undetected by routine diagnostic tests. Antimicrobial therapy might confer benefit for these patients.

Materials and methods

Over 10 years, we treated patients with chronic LUTS. Pyuria was adopted as the principal biomarker of infection. Urinary leucocyte counts were recorded from microscopy of fresh midstream urine (MSU) samples. Antibiotics were prescribed and the prescription adjusted to achieve a measurable clinical response and a reduction in pyuria.

Results

We treated 624 women [mean age = 53.4 years; standard deviation (SD) = 18] with chronic LUTS and pyuria. Mean duration of symptoms prior to presentation was 6.5 years. Only 16% of MSU cultures submitted were positive (≥10⁵ cfu ml^-1). Mean treatment length was 383 days [SD = 347; 95% confidence interval (CI) = 337–428]. Treatment was associated with a reduction in total LUTS (F = 98; p = 0.0001), 24-h frequency (F = 75; p = 0.0001), urinary urgency (F = 90; p = 0.0001), lower urinary tract pain (F = 108; p = 0.0001), voiding symptoms (F = 10; p = 0.002), and pyuria (F = 15.4; p = 0.0001). Full-dose first-generation antibiotics for UTI, such as cefalexin, nitrofurantoin, or trimethoprim, were combined with methenamine hippurate. We recorded 475 adverse events (AEs) during 273,762 treatment days. There was only one serious adverse event (SAE). We observed no increase in the proportion of resistant bacterial isolates.

Conclusion

This large case series demonstrates that patients with chronic LUTS and pyuria experience symptom regression and a reduction in urinary tract inflammation associated with antimicrobial therapy. Disease regression was achieved with a low frequency of AEs. These results provide preliminary data to inform a future randomized controlled trial (RCT).

Urothelial cells may indicate underlying bacteriuria in pregnancy at term: a comparative study

Background

Urinary tract infection is common in pregnancy. Urine is sampled from by mid-stream collection (MSU). If epithelial cells are detected, contamination by vulvo-vagial skin and skin bacteria is assumed. Outside pregnancy, catheter specimen urine (CSU) is considered less susceptible to contamination. We compared MSU and CSU methods in term pregnancy to test these assumptions.

Methods

Healthy pregnant women at term gestation (n = 32, median gestation 38 + 6 weeks, IQR 37 + 6–39 + 2) undergoing elective caesarean section provided a MSU and CSU for paired comparison that were each analysed for bacterial growth and bladder distress by fresh microscopy, sediment culture and immunofluorescent staining. Participants completed a detailed questionnaire on lower urinary tract symptoms. Epithelial cells found in urine were tested for urothelial origin by immunofluorescent staining of Uroplakin III (UP3), a urothelial cell surface glycoprotein. Urothelial cells with closely associated bacteria, or “clue cells”, were also counted. Wilcoxons signed rank test was used for paired analysis.

Results

Women reported multiple lower urinary tract symptoms (median 3, IQR 0–8). MSU had higher white blood cell counts (median 67 vs 46, z = 2.75, p = 0.005) and epithelial cell counts (median 41 vs 22, z = 2.57, p = 0.009) on fresh microscopy. The proportion of UP3+ cells was not different (0.920 vs 0.935, z = 0.08, p = 0.95), however MSU had a higher proportion of clue cells (0.978 vs 0.772, z = 3.17, p = 0.001). MSU had more bacterial growth on sediment culture compared to CSU specimens (median 8088 total cfu/ml vs 0, z = 4.86, p = 0.001). Despite this, routine laboratory cultures reported a negative screening culture for 40.6% of MSU specimens.

Conclusion

Our findings have implications for the correct interpretation of MSU findings in term pregnancy. We observed that MSU samples had greater bacterial growth and variety when compared to CSU samples. The majority of epithelial cells in both MSU and CSU samples were urothelial in origin, implying no difference in contamination. MSU samples had a higher proportion of clue cells to UP3+ cells, indicating a greater sensitivity to bacterial invasion. Urinary epithelial cells should not be disregarded as contamination, instead alerting us to underlying bacterial activity.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1606-z) contains supplementary material, which is available to authorized users.

Stimulus-associated urinary urges in overactive bladder syndrome

AIMS

Although anecdotal reports of urinary urgency at one's front door are common in overactive bladder syndrome (OAB), little research has been done on how one's front door and other stimuli are related to urinary symptoms. We hypothesized that individuals with OAB would have higher scores on the Urinary Cues Questionnaire, developed for this study to assess stimulus-associated urinary urges, than those without OAB.

METHODS

Online surveys were administered to 328 women age 18-40 years recruited from a respondent panel maintained by CINT such that one-third of the sample reported a diagnosis of OAB. The survey assessed OAB symptoms and the frequency with which participants associated 42 stimuli with the urge to urinate.

RESULTS

Psychometric analyses showed internal consistency estimates of the Urinary Cues Questionnaire of α = 0.97 and a test-retest correlation of 0.91. Women with OAB had significantly higher Urinary Cues Scores than those without OAB, with a t-test showing a large effect size of d = 1.49 (95%CI 1.24, 1.74), P < 0.001.

DISCUSSION

Behavioral treatments aimed at reducing the response to cues may be useful in OAB, but more research is needed on both treatment implications and on the trajectory of symptom development.

Somatic, psychological, and sexual triggers for overactive bladder syndrome in women

AIMS

Patients with overactive bladder (OAB) often describe somatic, psychological, and sexual triggers for their symptoms. The aim of this study was to characterize these triggers and assess their impact on patients' symptoms and quality of life (QoL).

METHODS

Patients who visited our urogynecologic clinic between August 2015 and March 2016 and diagnosed with OAB syndrome were asked to fill a questionnaire comprising 34 statements regarding SOmatic, Psychological, and Sexual Triggers for OAB (SOPSETO). Patients additionaly completed the UDI-6 and IIQ-7 questionnaires. Statistical analysis was performed to determine the prevalence of each trigger and its correlation with the UDI-6 and IIQ-7 scores.

RESULTS

Sixty four women enrolled in this study. The SOPSETO questionnaire was found to be relaiable with Cronbach's alpha of 0.73-0.88. Construct validity was high with good correlation between the SOPSETO and the UDI-6 and IIQ-7 questionnaires. The triggers which had the highest correlation with the total UDI-6 scores were: Being far from toilets (r = 0.32, P = 0.004), swimming (r = 0.44, P = 0.02), taking a shower/bath (r = 0.36, P = 0.004), touching water (r = 0.35, P = 0.004), stepping out of a car (r = 0.32, P = 0.014), and experiencing an orgasm (r = 0.59, P = 0.001). The triggers: Experiencing an orgasm (r = 0.4, P = 0.033), having intercourse (r = 0.53, P = 0.002), stepping out of a car (r = 0.45, P = 0.001), and touching water (r = 0.28, P = 0.03) most significantly correlated with the total IIQ-7 scores.

CONCLUSIONS

Certain somatic, psychological, and sexual factors may trigger OAB symptoms and are therefore potential targets for behavioral therapy of this disorder, and for further research regarding its pathophysiological mechanisms.

TRP channels in lower urinary tract dysfunction

Lower urinary tract dysfunction (LUTd) represents a major healthcare problem. Although it is mostly not lethal, associated social disturbance, medical costs, loss of productivity and especially diminished quality of life should not be underestimated. Although more than 15% of people suffer from a form of LUTd to some extent, pathophysiology often remains obscure. In the past 20 years, transient receptor potential (TRP) channels have become increasingly important in this field of research. These intriguing ion channels are believed to be the main molecular sensors that generate bladder sensation. Therefore, they are intensely pursued as new drug targets for both curative and symptomatic treatment of different forms of LUTd. TRPV1 was the first of its class to be investigated. Actually, even before this channel was cloned, it had already been targeted in the bladder, with clinical trials of intravesical capsaicin instillations. Several other polymodally gated TRP channels, particularly TRPM8, TRPA1 and TRPV4, also appear to play a prominent role in bladder (patho)physiology. With this review, we provide a brief overview of current knowledge on the role of these TRP channels in LUTd and their potential as molecular targets for treatment.

Relationship between Toe Temperature and Lower Urinary Tract Symptoms

OBJECTIVE

Cold stress can elicit increases in urinary urgency and frequency. We determined if there was a relationship between finger and toe temperatures and lower urinary tract symptoms (LUTS).

METHODS

We studied 50 people who visited a public health management seminar. The participants were divided into two groups according to self-described sensitivity to cold stress. The cold non-sensitive (CNS) group consisted of 3 males and 20 females (66.9 ± 10.8 years old), and the cold sensitive (CS) group consisted of 4 males and 23 females (65.8 ± 8.01 years old). Each participant was assessed to determine international prostate symptom score (IPSS), overactive bladder symptom score (OABSS), and quality of life (QOL) score. They were then instructed on lifestyle changes and exercises that could improve peripheral blood flow and provide relief for their LUTS. Next, the temperatures of their middle fingers and toes were measured before and after 5-10 min of the exercises. Two weeks later, the IPSS, OABSS, and QOL scores were reassessed.

RESULTS

Before exercise, the middle fingers were significantly warmer than the middle toes. Exercise had no significant effect on the middle finger temperature of either group; however, it did increase the middle toe temperature for both groups. The increase was greatest for the CS group. The CS group had higher LUTS storage symptoms than the CNS group, and these improved after 2 weeks of lifestyle changes and exercise.

CONCLUSION

Improvements in lifestyle and daily exercise may be effective for LUTS in CS people.

Intravesical Botulinum Toxin for Overactive Bladder Syndrome without Detrusor Overactivity

Objective:

To report our experience of intravesical botulinum toxin for idiopathic overactive bladder syndrome (OAB) without detrusor overactivity (DOA) on urodynamic assessment.

Patients and methods:

Data regarding presentation, diagnosis, urodynamic findings, date and dose of treatment, and outcomes were recorded prospectively for 94 patients undergoing intravesical botulinum toxin injection for idiopathic overactive bladder syndrome at our institution. The cohort included 19 patients without DOA on urodynamics. A positive response to treatment was defined as patient-reported improvement without the need for further treatment. ICIQ-OAB and UI scores, and bladder diary parameters were also recorded. Rates of urinary retention requiring intermittent or indwelling catheterisation were noted.

Results:

The overall response rate to treatment was 82% ( n = 94). Patients without DOA ( n = 19) had a response rate of 89%, which compared favourably with a response rate of 81% in patients with DOA ( n = 75). Overall, 29% of patients who were voiding normally prior to treatment required intermittent self-catheterisation after the procedure. The requirement for self-catheterisation did not appear to be influenced by urodynamic findings.

Conclusion:

These preliminary, non-randomised data suggest that intravesical botulinum toxin injection may be efficacious in patients with OAB symptoms without DOA. Further evaluation by means of a randomised, controlled trial is suggested.

Cold Stress and Urinary Frequency

There have been few studies regarding the onset of urinary sensations and frequent urination induced by sudden whole-body cooling. In this article, we review the relationship between cold stress and urinary frequency based mainly on our previous studies. A recent study showed that cold stress induces bladder overactivity in conscious rats, and these effects were mediated, at least in part, by α1A -adrenergic receptor (AR) and α1D -AR. Another study suggested that the resiniferatoxin-sensitive nerves present in the urinary bladder may also be involved in the regulation of detrusor activity associated with cold stress. The mammalian transient receptor potential (TRP) channel family consists of 28 channels subdivided into five different classes: TRPV (vanilloid), TRPC (canonical), TRPM (melastatin), TRPML (mucolipin), and TRPA (ankyrin). TRP channels function as multifunctional sensors at the cellular level. They can be activated by physical (voltage, heat, cold, mechanical stress) or chemical stimuli and binding of specific ligands. In 2002, it was reported that a nonselective cation channel, TRPM8, could be activated by both menthol and thermal stimuli (8-28 °C). We demonstrated the presence of TRPM8 in the skin from the legs and back of rats by immunofluorescence staining and that stimulation of this receptor by menthol causes urinary frequency. There have been other reports demonstrating roles of TRPM8 not related to its thermosensory function. Further studies are needed to clarify the mechanism of cold stress-induced urinary frequency, and the roles of TRPM8 in the micturition control system.

Defining urinary urgency: patient descriptions of "gotta go"

AIMS

Urgency is a key symptom in the diagnosis of overactive bladder (OAB), yet its definition and measurement are subject to continuing debate whether urinary urgency is a pathologic sensation or an intensification of normal desire to pass urine. The objective of this research was to explore the concept of urgency among participants with OAB symptoms and to evaluate the content validity of the urinary sensation scale (USS).

METHODS

Two qualitative studies were conducted among participants with OAB symptoms. For both studies, participants were interviewed on the USS to ascertain their ability to complete and interpret each response. Study 2 included open-ended questions to explore the concept of urgency with participants asked to describe "normal urge" and "urgency."

RESULTS

Thirty-one men and women (Study 1, n = 12; Study 2, n = 19) participated. Nearly all participants (n = 29) thought the word descriptions for the 1-5 scale were easy to comprehend and were able to differentiate among ratings by degree of severity. Study 2 noted little difference between continent (n = 9) and incontinent (n = 10) participant descriptions of "urge or desire to urinate" and "typical sensation." The majority of the continent (n = 6) and incontinent (n = 7) participants stated they have both "regular" sensations to urinate and "urgent" sensations to urinate.

CONCLUSIONS

This qualitative research provides evidence that men and women with OAB symptoms can distinguish between "normal" urge (desire) to urinate and "urgency" suggesting that urinary urgency is a continuum, rather than an all-or-none phenomenon. The USS demonstrated content validity and was acceptable to patients.

Botulinum toxin injections for adults with overactive bladder syndrome

BACKGROUND

Overactive bladder syndrome (OAB) is a common condition with a significant negative impact on quality of life characterised by urgency with or without urge incontinence, frequency and nocturia.  Intravesical botulinum toxin is being increasingly used to treat severe overactive bladder refractory to standard management.  An increasing body of literature is forming that supports this technique as effective, well tolerated, and safe.  This review is a substantial update of the 2007 review of the same title.

OBJECTIVES

The objective was to compare intravesical botulinum toxin with other treatments for neurogenic and idiopathic overactive bladder in adults. The hypothesis to be addressed were whether intravesical injection of botulinum toxin was better than placebo or no treatment; pharmacological and other non-pharmacological interventions; whether higher doses of botulinum toxin were better than lower doses; whether botulinum toxin in combination with other treatments was better than other treatments alone; whether one formulation of botulinum toxin is better than another; and whether one injection technique was better than another.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 23 February 2010). The Register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and handsearching of journals and conference proceedings. Additionally, all reference lists of selected trials and relevant review papers were searched. No limitations were placed on the searches.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for OAB in adults in which at least one management arm involved intravesical injection of botulinum toxin were included. Participants had either neurogenic OAB or idiopathic OAB with or without stress incontinence. Comparison interventions could include no intervention, placebo, lifestyle modification, bladder retraining, pharmacological treatments, surgery, bladder instillation techniques, neuromodulation, and different types, doses, and injection techniques of botulinum toxin.

DATA COLLECTION AND ANALYSIS

Binary outcomes were presented as relative risk and continuous outcomes by mean differences. Little data could be synthesised across studies due to differing study designs and outcome measures. Where applicable standard deviations were calculated from P values according to the formula described in section 7.7.3.3 of the Cochrane Handbook of Systematic Reviews of Interventions. Data were tabulated where possible with results taken from trial reports where this was not possible. Where multiple publications were found, the reports were treated as a single source of data.

MAIN RESULTS

Nineteen studies were identified that met the inclusion criteria.  Most patients in the studies had neurogenic OAB, but some included patients with idiopathic OAB.  All studies demonstrated superiority of botulinum toxin to placebo.  Lower doses of botulinum toxin (100 to 150 U) appeared to have beneficial effects, but larger doses (300 U) may have been more effective and longer lasting, but with more side effects.  Suburothelial injection had comparable efficacy to intradetrusor injection. The effect of botulinum toxin may last for a number of months and is dependent upon dose and type of toxin used. Patients receiving repeated doses do not seem to become refractory to botulinum toxin. Botulinum toxin appeared to have beneficial effects in OAB that quantitatively exceeded the effects of intravesical resiniferatoxin. Intravesical botulinum toxin appeared to be reasonably safe; however, one study was halted due to a perceived unacceptable rate of urinary retention. 

AUTHORS' CONCLUSIONS

Intravesical botulinum toxin appears to be an effective therapy for refractory OAB symptoms, but as yet little controlled trial data exist on benefits and safety compared with other interventions, or with placebo. Further robust data are required on long term outcomes, safety, and optimal dose of botulinum toxin for OAB.

A simple validated scale to measure urgency

PURPOSE

We validated a simple scale to measure urinary urgency.

MATERIALS AND METHODS

The new 10-item scale was validated using data from experiments using a single group repeated measure design. A total of 475 patients, including 411 females and 64 males, with a mean age of 57.3 years who had been diagnosed with overactive bladder were treated with a bladder retraining regimen and antimuscarinic agent (10 mg oxybutynin controlled release per night or 4 mg tolterodine slow release per night). At each visit patient urge symptoms were recorded by the scale. Reported average daily frequency and incontinence episodes were also recorded. Of patients who were not satisfied with the symptoms 130 had 25 mg imipramine per night added to their prescription and in 130 treatment was changed to 10 mg solifenacin per night.

RESULTS

Construct validity was tested by comparing the urgency scale to frequency and to incontinence (Spearman's rank correlation coefficient r = 0.38, p <0.001 and r = 0.15, p <0.001, respectively). Internal consistency showed Cronbach's alpha = 0.83. Test-retest reliability was determined in 30 patients and interobserver reliability was determined in 58 (Pearson's r = 0.99, p <0.001 and r = 0.99, p <0.001, respectively). Internal responsiveness in the imipramine add-on study in 130 patients showed a standardized response mean of 0.6 (p <0.001) and in the solifenacin swap study in 130 it showed a standardized response mean of 0.69, while external responsiveness showed a standardized response mean of 0.69 (each p <0.001).

CONCLUSIONS

This scale succeeded in all validation studies. This new scale may prove useful for measuring between-drug differences in efficacy and for monitoring treatment responses in patients with overactive bladder. It now must be tested in a proper double-blind, randomized, controlled trial.

Cold environmental stress induces detrusor overactivity via resiniferatoxin-sensitive nerves in conscious rats

AIMS

We determined if cold environmental stress induced detrusor overactivity in conscious rats. We then examined the role of resiniferatoxin (RTX)-sensitive nerves in this response.

METHODS

Three days prior to cystometric investigation, the urinary bladders of 12 female rats were cannulated. Six of the rats were treated with RTX 24 hr prior to cystometric investigation. The rats were exposed to three ambient temperature conditions: room temperature (RT, 27 degrees C) for 20 min, low temperature (LT, 4 degrees C) for 40 min, and RT again for 20 min. During each exposure, cystometric patterns of the rats were recorded. Additionally, neuronal structures of urinary bladders were visualized by immunohistochemistry.

RESULTS

When the conscious rats were suddenly transferred from RT to LT, the cooled rats exhibited micturition patterns of detrusor overactivity. After 20 min at LT, the response slowly improved. After returning to RT, the overactive detrusor response disappeared, reverting to patterns similar to those before transfer to LT. When the RTX-treated rats were exposed with cold stress, they also exhibited detrusor overactivity. However, it was significantly mitigated compared to the non-RTX-treated normal rats. The normal rats had distinct neuronal structures labeled with S100 and calcitonin gene-related peptide antibodies in the urinary bladders, but the RTX-treated rats had few.

CONCLUSION

Detrusor overactivity of the conscious rats was induced by cold environmental stress. A portion of the cold-stress detrusor overactivity might be mediated by RTX-sensitive neurological pathway. The cold-stress model would be useful to investigate lower urinary tract functions.

Botulinum toxin injections for adults with overactive bladder syndrome

BACKGROUND

Overactive bladder syndrome is a common condition with a significant negative impact on quality of life. Intravesical injection of botulinum toxin is increasingly used as an intervention for refractory overactive bladder, with a considerable body of case reports and series in the literature suggesting beneficial effects.

OBJECTIVES

The objective was to compare intravesical botulinum toxin injection with other treatments for neurogenic and idiopathic overactive bladder in adults. The hypotheses addressed were whether intravesical injection of botulinum toxin was better: than placebo or no treatment, pharmacological and other non-pharmacological interventions, whether higher doses of botulinum toxin were better than lower doses, whether botulinum toxin in combination with other treatments was better than other treatments alone, whether one formulation of botulinum toxin is better than another, and whether one injection technique was better than another.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 22 November 2005). The register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and handsearching of journals and conference proceedings. Additionally, all reference lists of selected trials were searched. No limitations were placed on the searches.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for overactive bladder syndrome in adults in which at least one management arm involved intravesical injection of botulinum toxin were included. Participants had either neurogenic or idiopathic overactive bladder with or without stress incontinence. Comparison interventions could include no intervention; placebo; lifestyle modification; bladder retraining; pharmacological treatments; surgery; bladder instillation techniques; neuromodulation; and different types, doses, and injection techniques of botulinum toxin.

DATA COLLECTION AND ANALYSIS

Binary outcomes were presented as relative risk and continuous outcomes by mean differences. No data could be synthesised across studies due to differing designs and outcome measures. Data were tabulated where possible with results taken from trial reports where this was not possible. Where multiple publications were found, the reports were treated as a single source of data.

MAIN RESULTS

Eight studies met the inclusion criteria. Results varied between studies. For the most part, studies reported superiority of botulinum toxin A to placebo in such outcomes as incontinence episodes, bladder capacity, maximum detrusor pressure, and quality of life. Low doses of botulinum toxin (100U to150U) appeared to have beneficial effects, but higher doses (300U) may have been more effective. Botulinum toxin appeared to have beneficial effects in overactive bladder that quantitatively exceeded the effects of intravesical resiniferatoxin.

AUTHORS' CONCLUSIONS

Intravesical botulinum toxin shows promise as a therapy for overactive bladder symptoms, but as yet too little controlled trial data exist on benefits and safety compared with other interventions, or with placebo. Practitioners should be aware that at present there is little more than anecdotal evidence, in the form of case reports to support the efficacy of intravesical botulinum toxin; there is not much in the way of substantial, robust safety data. Furthermore, the optimal dose of botulinum toxin for efficacy and safety has not yet been demonstrated.

Bladder sensory desensitization decreases urinary urgency

Background

Bladder desensitization has been investigated as an alternative treatment for refractory detrusor overactivity. Most open and controlled clinical trials conducted with intravesical RTX showed that desensitization delays the appearance of involuntary detrusor contractions during bladder filling and decreases the number of episodes of urgency incontinence.

Urgency is being recognised as the fundamental symptom of overactive bladder (OAB), a symptomatic complex which recent epidemiological studies have shown to affect more than 10% of the Western population. As anti-muscarinic drugs, the first line treatment for OAB, are far from being able to fully control urgency, the opportunity to test other therapeutic approaches is created. The present work was, therefore, designed as an exploratory investigation to evaluate the effect of bladder desensitization on urinary urgency.

Methods

Twenty-three OAB patients with refractory urgency entered, after given informed consent, a 30 days run-in period in which medications influencing the bladder function were interrupted. At the end of this period patients filled a seven-day voiding chart where they scored, using a 0–4 scale, the bladder sensations felt before each voiding. Then, patients were instilled with 100 ml of 10% ethanol in saline (vehicle solution) and 30 days later a second seven-day voiding chart was collected. Finally, patients were instilled with 100 ml of 50 nM RTX in 10% ethanol in saline. At 1 and 3 months additional voiding charts were collected.

At the end of the vehicle and 3 months period patients were asked to give their subjective impression about the outcome of the treatment and about the willingness to repeat the previous instillation.

Results

At the end of the run-in period the mean number of episodes of urgency per week was 71 ± 12 (mean ± SEM). After vehicle instillation, the mean number of episodes of urgency was 56 ± 11, but only 4 patients (17%) considered that their urinary condition had improved enough to repeat the treatment. At 1 and 3 months after RTX the number of episodes of urgency decreased to 39 ± 9 (p = 0.002) and 37 ± 6 (p = 0.02), respectively (p indicates statistical differences against vehicle). The percentage of patients with subjective improvement after RTX and willing to repeat the instillation at a later occasion was 69%.

Conclusion

In OAB patients with refractory urgency bladder desensitization should be further investigated as an alternative to the standard management. Additionally, the specific effect of RTX on TRPV1 receptors suggests that urothelium and sub-urothelial C-fibers play an important role to the generation of urgency sensation.

Urgency assessment in the evaluation of overactive bladder (OAB)

Overactive bladder (OAB) is a highly prevalent urinary condition with a profound affect on quality of life. Urinary urgency is the cornerstone symptom that defines OAB and drives all subsequent OAB symptoms. The clinical assessment and measurement of urgency has been limited by its definition, limited understanding of well-defined pathophysiology, and psychometric measurement properties. This review outlines the important issues relevant to the clinical assessment and measurement scales commonly used to evaluate and measure urinary urgency. This will have important implications toward further understanding and advancing the field of overactive bladder.