Cure of Underactive and Overactive Bladder Symptoms in Women by 1,671 Apical Sling Operations Gives Fresh Insights into Pathogenesis and Need for Definition Change

Association between voiding lower urinary tract symptoms and findings on dynamic magnetic resonance imaging with regard to pelvic organs and their supportive structures

OBJECTIVES

Pelvic organ prolapse (POP) causes voiding lower urinary tract symptoms (vLUTS). In the present study, we investigated the association between vLUTS and pelvic organ mobility (POM), including relevant supportive structures, on dynamic magnetic resonance imaging (dMRI).

METHODS

We included 118 patients who had POP of stage II or less before straining and stage III or more when straining during dMRI. The presence of vLUTS and overactive bladder (OAB) was determined by a voiding subscore of the International Prostate Symptom Score (vIPSS) ≥5 and the OAB symptom score, respectively. POM was measured by dMRI before and during straining, and patients with and without vLUTS as well as patients with and without vLUTS and/or OAB were compared. p < .05 was considered to be statistically significant.

RESULTS

According to vIPSS, 42 patients (35.6%) had vLUTS. On dMRI, patients with vLUTS showed a significantly more ventral position and/or movement of the bladder and cervix. Moreover, patients with vLUTS and OAB had significantly more ventral movement of the uterine cervix and a larger strain on imaginary uterosacral and cardinal ligaments than those without these symptoms. In addition, patients with vLUTS and OAB had significantly higher vIPSS than those with vLUTS alone.

CONCLUSIONS

vLUTS may be associated with the proximity of the bladder and cervix to the pubic bone and consequent compression of the urethra by the prolapsed organs. vLUTS with OAB might indicate more advanced lower urinary tract dysfunction than vLUTS alone.

Defining urge as an uncontrolled micturition explains pathogenesis, informs cure and helps solve the burgeoning OAB crisis

BACKGROUND

Parallel with the demographic ageing crisis, is a disabling overactive bladder (OAB) crisis (urgency/frequency/nocturia), 30% prevalence in older women, pathogenesis stated as unknown and, according to some learned societies, incurable.

HYPOTHESIS/AIMS

To review International Continence Society and Integral System paradigms to test our thesis that OAB per se is not a pathological condition, rather, a prematurely activated uncontrolled micturition; pathogenesis being anatomical damage in a nonlinear feedback control system comprising cortical and peripheral (muscle/ligament) components.

METHODS

We examined studies from basic science, anatomy, urodynamics, ultrasonic and video xrays, ligament repairs, from which we created a nonlinear binary model of bladder function. We applied a Chaos Theory feedback equation, Xnext  = Xc(1 - X) to test our hypothesis against existing concepts and hypotheses for OAB pathogenesis.

RESULTS

The bladder has ONLY two modes, EITHER closed OR open (micturition). Closure is reflexly controlled cortically and peripherally: muscles contracting against ligaments stretch the vagina to suppress afferent signals to micturate from urothelial stretch receptors. "OAB" can be caused by anatomical damage anywhere in the model, by childbirth or age-weakened ligaments, which can be repaired to cure all three OAB symptoms. Urodynamic "DO" graphs are interpreted anatomically and by the feedback equation.

CONCLUSION

OAB is in crisis. Our thesis of OAB as an uncontrolled micturition from anatomical defects in the bladder control system provides fresh directions for further development of new treatments, nonsurgical and surgical, to help break the crisis and bring hope and cure to 600 million women sufferers.

THE CASE AGAINST urethral failure is not a critical factor in female urinary incontinence. Now what? The integral theory system

SUBJECT OF THE DEBATE: "Urethral failure is a critical factor in female urinary incontinence Now what?" The CASE FOR by Hokanson, DeLancey pinpointed inadequacy of bladder causation for urgency urinary incontinence (UUI) and poor urethral support for stress urinary incontinence (SUI) as responsible for long-standing lack of progress in incontinence science. They proposed "Urethral failure" as causation for SUI and UUI. The CASE AGAINST, by Peter Petros agrees "abnormal detrusor function as cause for (UUI) is a failed concept, and SUI surgery results are sometimes suboptimal, but rejects "urethral failure" as cause for UUI and SUI. In answer to, "Now what?," Petros presents the Integral Theory System. SUI and UUI are dysfunctions of the bladder's binary control mechanism, mainly ligament laxity because of defective collagen/elastin. The urethra is an emptying tube. Pelvic muscle forces reflexly contract against ligaments to close urethra, open it (micturition) and stretch the vagina underlying urethelial stretch receptors to mechanically support them, preventing premature activation of micturition (UUI). High validated cure rates for SUI and UUI by repair of weakened ligaments question viability of the "urethral failure" concept. CONCLUSIONS: The major achievement of this debate (both sides) is not what causes UUI or SUI, or what doesn't, though clearly, this is important. It is calling out a 50-year ossification of the whole construct of UUI, ranging from flawed definitions to systematic denial of known cures, all of which have stalled treatment of the one billion women who suffer with incontinence. The time has come for change.

An anatomical pathogenesis of lower urinary tract definitions from the 2002 ICS report symptoms, conditions, syndromes, urodynamics

AIM

To present an anatomical pathogenesis parallel with the 2002 International Continence Society Lower Urinary Tract (LUTS) definitions standardization Report 2002.

METHODS

Each LUTS section is discussed using the same numbers as the Report.

RESULTS

Normal function Bladder control is binary, with two reflexes alternating, either closure (dominant) or open (micturition), with the same cortical and peripheral components: three directional muscle forces contracting against pubourethral (PUL) and uterosacral (USL) ligaments for closure, two against uterosacral ligaments for micturition. Dysfunction OAB symptoms reflect a prematurely activated micturition; PUL/USL weakness prevents muscle forces from controlling afferent urothelial emptying signals. Stress urinary incontinence is a consequence of weak PULs allowing posterior muscle forces to open the urethra during effort. Lax USLs weaken contractile force of the posterior urethral opening vectors, so detrusor has to contract against an unopened urethra. This is experienced as "obstructive micturition."

CONCLUSIONS

Anatomical analysis indicates the ICS definitions are fundamentally sound, except for "OAB" which implies detrusor causation. Minor changes, OAB to "overactivated" bladder allow causation outside of bladder. This construct supports OAB and its component symptoms as a syndrome, as intuited by the Committee, (albeit as a prematurely activated micturition), retains the acronym, explains OAB cure by ligament repair, and incontinence pathogenesis from two post-2002 syndromes which need an addition to the definitions, Posterior Fornix Syndrome (of which OAB is a component) and Tethered Vagina Syndrome, which is the basis for skin-grafting cure of the 30%-50% of women who continue leaking urine massively after successful obstetric fistula closure.

Overactive bladder (OAB): a failed concept needing revision to accommodate an external anatomical control system

THESIS AND AIMS

In 45 years, the definitions and practice of the urodynamically based overactive bladder (OAB)/detrusor overactivity (DO) system have failed to adequately address pathogenesis and cure of urinary urge incontinence, frequency and nocturia.

METHODS

We analysed the OAB syndrome with reference to the Integral Theory paradigm's (ITS) binary feedback system, where OAB in the female is viewed as a prematurely activated, but otherwise normal micturition caused mainly, but not entirely, by ligament damage/laxity. The ITS Clinical Assessment Pathway which details the relationships between structural damage (prolapse), ligaments and dysfunction (symptoms) is introduced.

RESULTS

The ITS was able to "better explain" OAB pathophysiology in anatomical terms with reference to the binary model. The phasic patterns diagnostic of "detrusor overactivity" are explained as a struggle for control by the closure and micturition reflexes. The exponentially determined relationship between urethral diameter and flow explains why obstructive patterns occur, why they do not and why urine may leak with no recorded pressure. Mechanically supporting ligaments ("simulated operations") during urodynamic testing can improve low urethral pressure, negative pressure during coughing with SUI and diminish urge sensation or even DO patterns, transforming urodynamics from non-predictive test to accurate predictor of continence surgery results. High cure rates for OAB by daycare repair of damaged ligaments is a definitive test of the binary system's validity.

CONCLUSION

Conceptual progression of OAB to the Integral Theory paradigms's prematurely activated micturition validates OAB component symptoms as a syndrome, explains pathogenesis, and unlocks a new way of understanding, diagnosing, treating and researching OAB.

Vulvodynia: a neuroinflammatory pain syndrome originating in pelvic visceral nerve plexuses due to mechanical factors

This short opinion aimed to present the evidence to support our hypothesis that vulvodynia is a neuroinflammatory pain syndrome originating in the pelvic visceral nerve plexuses caused by the failure of weakened uterosacral ligaments (USLs) to support the pelvic visceral nerve plexuses, i.e., T11–L2 sympathetic and S2–4 parasympathetic plexuses. These are supported by the USLs, 2 cm from their insertion to the cervix. They innervate the pelvic organs, glands, and muscles. If the USLs are weak or lax, gravitational force or even the muscles may distort and stimulate the unsupported plexuses. Inappropriate afferent signals could then be interpreted as originating from an end-organ site. Activation of sensory visceral nerves causes a neuro-inflammatory response in the affected tissues, leading to neuroproliferation of small peripheral sensory nerve fibers, which may cause hyperalgesia and allodynia in the territory of the damaged innervation. Repair of the primary abnormality of USL laxity, responsible for mechanical stimulation of the pelvic sensory plexus, may lead to resolution of the pain syndrome.

Pelvic-floor function, dysfunction, and treatment

The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system's multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training. The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory's explanations of function and dysfunction.

Association between overactive bladder and pelvic organ mobility as evaluated by dynamic magnetic resonance imaging

Overactive bladder (OAB) is a prevalent condition, which negatively impacts patients’ quality of life. Pelvic organ prolapse (POP), also prevalent in women, has been recognized as an important etiology of female OAB, although the pathophysiological mechanisms remain controversial. In this study, we reviewed findings of dynamic magnetic resonance imaging (dMRI) in 118 patients with POP and investigated the association between dMRI findings, including positions and mobilities of pelvic organs as well as parameters of pelvic organ support and bladder outlet obstruction (urethral kinking), and OAB in order to elucidate the pathophysiology of OAB in patients with POP. Our results showed that compared with non-OAB patients, OAB patients had a significantly higher body mass index, more severe pelvic floor muscle impairment, and more profound supportive defects in the uterine cervix (apical compartment). On the other hand, dMRI parameters showed hardly any significant difference between patients with mild and moderate to severe OAB. These findings may imply that levator ani impairment and defective supports of the apical compartment could be associated with the presence of OAB and that the severity of OAB could be affected by factors other than those related to pelvic organ mobility and support or urethral kinking.

Symptoms of voiding dysfunction and other coexisting pelvic floor dysfunctions: the impact of transvaginal, mesh-augmented sacrospinous ligament fixation

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the prevalence for voiding dysfunction and if symptom improvement can be achieved by adequate pelvic floor surgery.

METHODS

We evaluated the Propel Study data from 281 women with pelvic organ prolapse (POP) stage 2-4. Bother caused by obstructive micturition, voiding dysfunction, and coexisting pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI) preoperatively and 6, 12, and 24 months after vaginal prolapse repair. Successful reconstruction (Pelvic Organ Prolapse Quantification [POP-Q] stage 0-I throughout the 2-year follow-up at all compartments, "responders"), was compared with all others ("non-responders").

RESULTS

Prevalence of voiding dysfunction was significantly reduced after surgery for all patients with "moderate" to "quite a bit" of bother ("R2") regarding all examined PFDI questions. Defects of the posterior/apical compartment and lower stage defects were found to cause obstructive micturition, which improved significantly after POP surgery. Six months after surgery, the prevalence of R2 for voiding dysfunction symptoms was reduced significantly for responders compared with non-responders. Significant reduction of R2 in patients with rectoceles could be shown for some PFDI questions, whereas the rate was lower in patients with cystoceles. Other pelvic floor symptoms often coexisted in patients with voiding dysfunction symptoms and improved significantly after surgery as well.

CONCLUSIONS

Symptoms of voiding dysfunction are frequent in female patients with POP and can significantly improve after vaginal mesh-augmented prolapse repair even for posterior and minor defects. Before counseling patients to undergo POP surgery because of their obstructive symptoms, other causes of voiding dysfunction must first have been ruled out.

A four month squatting-based pelvic exercise regime cures day/night enuresis and bowel dysfunction in children aged 7-11 years

INTRODUCTION

In 2004, Patricia Skilling developed a new squatting-based pelvic floor rehabilitation method based on strengthening the three reflex pelvic muscles and ligaments hypothesized to control the closure and micturition reflexes. We adapted these methods to test our hypothesis that day/night enuresis was due to the inability of these muscles/ligaments to control an inappropriately activated micturition reflex.

MATERIAL AND METHODS

The trial commenced as a randomized control trial to be conducted over 4 months, but was converted to a prospective trial at 4 weeks by order of the Ethics Committee. A total of 48 children, 7.6 ±2.5 years, 34 females, 14 males, had strictly supervised exercises twice daily, 10 squats, 10 bridge, fitball exercises involving proprioception exercises with surface perineal electromyogram (EMG) once a week.Eligibility criteria were daytime urine leakage plus night-time bedwetting. Exclusion criterion was refusal to sign consent forms. Assessment was done by intention to treat. The criterion for cure was complete dryness.

RESULTS

At 1st review (4 weeks) 12/24 in the treatment group reported total cure of wetting; 41/48 children (86%) were cured of both daytime/nighttime enuresis (p <0.001) at 4 months. There were no adverse events. Secondary outcomes were concomitant cure of constipation, fecal incontinence, urinary retention as predicted by the underlying integral theory of incontinence.

CONCLUSIONS

We believe our methods accelerated normal childhood strengthening of muscles/ligaments which control inappropriate activation of the micturition reflex which we hypothesize is the basis for daytime/nighttime enuresis. This is a simple treatment, needs diligent application and validation by others.

Comparison of Two Numerical Parameters to Assess Detrusor Contractility in Prognosing Short-Term Outcome after Transurethral Resection of the Prostate

OBJECTIVE

To investigate and compare the influence of two numerical detrusor contractility parameters, the bladder contractility index (BCI) and the maximum Watts factor (WFmax), on transurethral resection of the prostate (TURP) outcome.

METHODS

A retrospective study was conducted on 236 patients who had undergone urodynamic assessment preoperatively and TURP for benign prostatic obstruction. They were evaluated by International Prostate Symptom Score (IPSS) and uroflowmetry preoperatively and 3 months postoperatively. Related criteria were established to determine the overall efficacy of TURP. Logistic regression analysis and receiver operating characteristic curves were made to investigate the influence of the BCI and WFmax on TURP efficacy.

RESULTS

Among the 236 patients, 195 treatments were effective and 41 ineffective. Multivariate analysis showed that both the BCI (OR 1.038) and the WFmax (OR 1.291) could influence TURP efficacy. For predicting TURP efficacy, the optimal cut-off values of the BCI and WFmax were 98.7 and 10.27 W/m2, respectively. The AUC, sensitivity and specificity of the BCI were 0.722, 78.5% and 61.0%; those of the WFmax were 0.761, 73.9% and 73.2%, with no significant difference (p > 0.05).

CONCLUSIONS

To some extent, the BCI and the WFmax can predict TURP efficacy equally well. A discrimination level of 10.27 W/m2 may be a threshold value for detrusor underactivity (DU); as regards the BCI, the current threshold value is appropriate to diagnose DU.