Recent advances in the understanding and management of underactive bladder

Analysis of clinical efficacy of sacral magnetic stimulation for the treatment of detrusor underactivity

Objective

The objective of this study was to investigate the effectiveness and safety of sacral magnetic stimulation (SMS) in the management of detrusor underactivity (DU).

Methods

We retrospectively analyzed 66 patients with detrusor underactivity treated at Hangzhou Third People's Hospital from January 2020 to October 2024, divided into two groups (33 cases each). Both groups had confirmed detrusor underactivity via urodynamic studies. The control group received conventional treatment (medication, catheterization, bladder training), while the observation group received SMS therapy. Urination diaries, urodynamic parameters and self-rating anxiety scale (SAS) were collected before and after the 4-week treatment to evaluate SMS efficacy and safety.

Results

All patients in the observation group completed the course of sacral magnetic stimulation without experiencing any serious complications. After treatment, the observation group showed a significant reduction in the number of daily urinations, nocturnal urinations, SAS score and residual urine volume (RUV) (p < 0.05) compared with the control group. There was no statistically significant difference in maximum cystometric capacity (MCC) (p > 0.05). However, improvements were observed in SAS score, Detrusor Pressure at Maximum Flow (Pdet), Bladder Contractility Index (BCI), Maximum urinary Flow Rate (Qmax) and Average Urinary Flow Rate (Qavg) (p < 0.05). The effective rate in the observation group was 78.78%, significantly higher than that in the control group (p < 0.05). Although there was a slight decrease in the effective rate during the 6-month follow-up, the difference was not statistically significant (p > 0.05).

Conclusion

In conclusion, sacral magnetic stimulation therapy has demonstrated effectiveness in improving urinary function in patients with detrusor underactivity while maintaining a high level of safety.

Electroacupuncture for urinary retention after stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

Electroacupuncture (EA) is one of the non-pharmacological therapies in traditional Chinese medicine to treat urinary retention. The objective of this meta-analysis is to assess the efficacy of electroacupuncture in the treatment of urinary retention after stroke.

METHODS

Overall, seven electronic databases were searched until December 31, 2023, and randomized control trials about EA for urinary retention after stroke were reviewed. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias for included studies. The meta-analysis was conducted by RevMan 5.4 and Stata/MP 17.0 software.

RESULTS

Eleven studies with a total of 856 participants were included in this meta-analysis. EA treatment yielded an improved reduction in the post-void residual (PVR) (mean difference [MD]: 37.85, 95 % confidence interval [CI]: 55.09 to -20.61 p < 0.0001) and the weight of diaper pads (MD: 38.87, 95 % CI: 42.68 to -335.06). Further analysis indicated that EA improved the effectiveness ratio (risk ratio [RR]: 1.36, 95 % CI: 1.20 to 1.53, p < 0.00001), the function of the bladder (MD: 0.45, 95 % CI: 0.61 to -0.30), and the quality of life (MD: 1.15, 95 %: CI: 2.10 to -0.20) in comparison to normal treatment and simple acupuncture.

CONCLUSION

EA may be an effective way and reasonable modality to incorporate into the multiple prevention and therapy for urinary retention after stroke. The wide application of EA could be associated with the improvement of bladder and life quality and decline in the PVR for patients after stroke with urinary retention.

Detrusor underactivity is associated with metabolic syndrome in aged primates

Lower urinary tract (LUT) dysfunction is prevalent in the elderly population, and clinical manifestations include urinary retention, incontinence, and recurrent urinary tract infections. Age-associated LUT dysfunction is responsible for significant morbidity, compromised quality of life, and rising healthcare costs in older adults, but its pathophysiology is not well understood. We aimed to investigate the effects of aging on LUT function by urodynamic studies and metabolic markers in non-human primates. Adult (n = 27) and aged (n = 20) female rhesus macaques were evaluated by urodynamic and metabolic studies. Cystometry showed detrusor underactivity (DU) with increased bladder capacity and compliance in aged subjects. Metabolic syndrome indicators were present in the aged subjects, including increased weight, triglycerides, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), and high sensitivity C-reactive protein (hsCRP), whereas aspartate aminotransferase (AST) was unaffected and the AST/ALT ratio reduced. Principal component analysis and paired correlations showed a strong association between DU and metabolic syndrome markers in aged primates with DU but not in aged primates without DU. The findings were unaffected by prior pregnancies, parity, and menopause. Our findings provide insights into possible mechanisms for age-associated DU and may guide new strategies to prevent and treat LUT dysfunction in older adults.

The inFlow intraurethral valve-pump for women with detrusor underactivity: A summary of peer-reviewed literature

Context: Detrusor underactivity (DUA) in women can result in urinary retention and the need for chronic bladder drainage management. Without a cure for urinary retention due to DUA, treatment options are focused on effective bladder drainage most often by intermittent or continuous catheter drainage. The inFlow intraurethral valve pump was FDA approved for use in women with this condition in 2014.Methods: Using a literature search, this clinical review sought to explore the epidemiology and commonly used treatment options for women with DUA and critically examine all available studies of the inFlow urinary prosthesis.Results: Due to a lack of effective treatments to improve detrusor function, DUA is generally considered incurable and there are limited treatment options which mostly focus on effective bladder drainage. The inFlow urinary prosthesis is a unique technology which utilizes a nonsurgically inserted urethral device for females to assist with bladder drainage due to DUA. The inFlow urinary prosthesis has been used in Europe and elsewhere for 20 years and is the subject of seven peer-reviewed clinical studies. For those that tolerate the device (about half), the inFlow urinary prosthesis has a low infection rate and side effect profile, is easy to use, and can normalize urination by returning autonomy to patients and thus improve their quality of life.Conclusion: There is no cure for women with DUA. Bladder drainage can be managed by intermittent or continuous catheterization. Appropriately selected women interested in an alternative to catheterization may be offered an on-device trial of the inFlow urinary prosthesis.

Sacral neuromodulation in patients with detrusor underactivity: Is biological sex an indicator?

OBJECTIVES

This study aimed to report sacral neuromodulation (SNM) outcomes in detrusor underactivity (DU).

METHODS

A multicentric, multinational, retrospective case series was conducted between March 2017 and June 2021 in three different referral centers. Initial test phase stimulation included either a percutaneous nerve evaluation (PNE) or an advanced lead evaluation test phase (ALTP) before permanent SNM implantation. The test phases were performed under local anesthesia, either in the outpatient (PNE) or operating room (ALTP), in the prone position, which was implanted in the third or fourth sacral foramina under fluoroscopic guidance. Patients with favorable response to the initial test phase during the first 2 weeks underwent the implantable pulse generator (IPG) implantation (Medtronic neurostimulation generator device InterStim™). Favorable response was defined as ≥ 50% improvement in symptoms, frequency of clean intermittent catheterization (CIC) and/or decrease in postvoid residual (PVR), increase in voided volume, or improvement in bladder voiding efficiency (BVE) based on the bladder diary.

RESULTS

Fifty-eight patients were recruited with a mean age of 39.95 ± 15.28 years. Among the 58 cases, 36 (62.1%) patients responded to the initial stage. Of these, 12 patients (30.8%) with non-neurogenic etiology and nine patients (52.9%) with neurologic etiology did not respond to the initial test phase; thus, they did not undergo full implantation (p = 0.141). Voided volume, PVR, and the median maximum flow rate (Qmax) improved significantly (p < 0.001) in both sexes; however, there was no statistical difference between both genders. Most female cases (78.3%), and nearly half of the men (51.4%), responded to the test phase and were candidates for the IPG phase. Among the 35 cases who underwent IPG, 27 patients (72.2% of males, and 77.8% of females; p = 0.700) had a favorable response to IPG. 46.6% of patients had a successful outcome at the end of the study.

CONCLUSION

This multicentric study showed that SNM effectively and safely provided symptom improvement in refractory DU in males similar to females which is an important finding as previously it has been suggested that SNM works better in nonobstructive urinary retention in women and not in women.

[Therapeutic effects of sacral neuromodulation on detrusor underactivity]

OBJECTIVE

To evaluate the effects of sacral neuromodulation (SNM) on detrusor underactivity (DUA).

METHODS

From December 2019 to April 2020, 6 patients with DUA who had been treated with SNM were assessed retrospectively. The average age was 58 years (46-65 years), with 3 males and 3 females. All the patients were diagnosed with DUA by urodynamics examination. Obstruction of bladder outlet was excluded through the cystoscopy. No patient had the history of neurological disease. All the patients were placed with the bladder colostomy tube before SNM. One female patient accepted the trans-urethral resection of bladder neck. Two male patients accepted the trans-urethral resection of prostate. All the 3 patients had no improvement of void symptom after the urethral operation. Before SNM, the average 24 h times of voiding was 23.8 (18-33), average volume of every voiding was 34.2 mL (10-50 mL), average residual volume was 421.7 mL (350-520 mL). The preoperative and postoperative 24 h urine frequency, average voided volume, and average residual urine volume were compared respectively.

RESULTS

Totally 6 patients underwent SNM with stage Ⅰ procedure. The operation time for stage Ⅰ procedure was 62-135 min (average 90 min). After an average follow-up of two weeks, stage Ⅱ procedure was performed on responders. Four patients accepted stage Ⅱ procedure (conversion rate 66.7%), the other two patients refused the stage Ⅱ procedure because the urine frequency did not reach the satisfied level. But all the patients had the improvement of residual urine volume. For the 4 patients at the follow-up of 10-15 months, the improvement of void was still obvious. For the all patients after stage Ⅰ procedure, the average 24 h urine frequency reduced to 13.5 times (9-18 times, P < 0.001), the average voided volume increased to 192.5 mL (150-255 mL, P < 0.001), and the average residual urine volume reduced to 97.5 mL (60-145 mL, P < 0.001). No adverse events, such as wound infection or electrode translocation were detected during an average follow-up of 11.3 months. Only one of the 4 patients who received the stage Ⅱ procedure did the intermittent catheterization for one time each day.

CONCLUSION

SNM provides a minimal invasive approach for the management of DUA.

[Therapeutic effects of sacral neuromodulation on detrusor underactivity]

OBJECTIVE

To evaluate the effects of sacral neuromodulation (SNM) on detrusor underactivity (DUA).

METHODS

From December 2019 to April 2020, 6 patients with DUA who had been treated with SNM were assessed retrospectively. The average age was 58 years (46-65 years), with 3 males and 3 females. All the patients were diagnosed with DUA by urodynamics examination. Obstruction of bladder outlet was excluded through the cystoscopy. No patient had the history of neurological disease. All the patients were placed with the bladder colostomy tube before SNM. One female patient accepted the trans-urethral resection of bladder neck. Two male patients accepted the trans-urethral resection of prostate. All the 3 patients had no improvement of void symptom after the urethral operation. Before SNM, the average 24 h times of voiding was 23.8 (18-33), average volume of every voiding was 34.2 mL (10-50 mL), average residual volume was 421.7 mL (350-520 mL). The preoperative and postoperative 24 h urine frequency, average voided volume, and average residual urine volume were compared respectively.

RESULTS

Totally 6 patients underwent SNM with stage Ⅰ procedure. The operation time for stage Ⅰ procedure was 62-135 min (average 90 min). After an average follow-up of two weeks, stage Ⅱ procedure was performed on responders. Four patients accepted stage Ⅱ procedure (conversion rate 66.7%), the other two patients refused the stage Ⅱ procedure because the urine frequency did not reach the satisfied level. But all the patients had the improvement of residual urine volume. For the 4 patients at the follow-up of 10-15 months, the improvement of void was still obvious. For the all patients after stage Ⅰ procedure, the average 24 h urine frequency reduced to 13.5 times (9-18 times, P < 0.001), the average voided volume increased to 192.5 mL (150-255 mL, P < 0.001), and the average residual urine volume reduced to 97.5 mL (60-145 mL, P < 0.001). No adverse events, such as wound infection or electrode translocation were detected during an average follow-up of 11.3 months. Only one of the 4 patients who received the stage Ⅱ procedure did the intermittent catheterization for one time each day.

CONCLUSION

SNM provides a minimal invasive approach for the management of DUA.

Detrusor underactivity influences the efficacy of TURP in patients with BPO

PURPOSE

To investigate the effect of detrusor underactivity on the efficacy of TURP in patients with benign prostate obstruction.

METHODS

A retrospective study of 350 patients with benign prostate obstruction who underwent TURP was carried out. Different degrees of bladder outlet obstruction were grouped by the bladder outlet obstruction index. ROC curves were used to calculate the optimal cut-off point for the bladder contractility index used to divide the DU patients into mild DU and severe DU patients. The effect of DU on the efficacy of TURP in benign prostate obstruction patients was studied by comparing the subjective and objective parameters preoperatively and 3 months postoperatively between severe DU, mild DU and non-DU benign prostate obstruction patients in two obstruction groups (20 ≤ BOOI < 40 and BOOI ≥ 40).

RESULTS

According to the ROC curve, the optimal cut-off point for the bladder contractility index was 82; thus, 69 patients were considered mild DU patients (82 ≤ BCI < 100), 67 patients were considered severe DU patients (BCI < 82), and 214 patients were considered non-DU patients (BCI ≥ 100). Both the postoperative subjective and objective parameters of the non-DU, mild DU and severe DU patients significantly improved in two obstruction groups. However, in the 20 ≤ BOOI < 40 group, the successful improvement rates for the IPSS, IPSS-S, IPSS-V, QoL and fQmax in the severe DU patients were only 38.2%, 38.2%, 44.1%, 41.2% and 38.2%, respectively.

CONCLUSION

Patients with varying degrees of benign prostate obstruction can benefit from TURP, but for patients with severe DU in the 20 ≤ BOOI < 40 group, TURP should be considered only after deliberation.

Understanding underactive bladder: a review of the contemporary literature

Underactive bladder (UAB) is characterized by prolonged voiding, hesitancy, and slow and/or intermittent stream with or without a sensation of incomplete bladder emptying. The overlap of UAB lower urinary tract symptoms with those of overactive bladder or bladder outlet obstruction, as well as its multifactorial etiology, make UAB study, as well as its diagnosis and management, a very arduous and challenging task. Therefore, despite its incidence and significant impact in the quality of life of both men and women, UAB remains a poorly understood urologic condition with insufficient and ineffective treatment options available. In this review, we will focus on the etiology theories that have been proposed and the animal models available to test those theories.

Detrusor underactivity in women: A current understanding

AIMS

To examine the current understanding and management of detrusor underactivity (DUA) and underactive bladder (UAB) in women.

METHODS

A review of the current literature was performed with a specific focus on new management strategies and treatment options for women with DUA and UAB.

RESULTS

DUA has become an area of increased interest in recent years. Affecting up to 45% of older women undergoing urodynamic evaluation for non-neurogenic lower urinary tract symptoms, DUA is common. There are a variety of possible etiologies including neurogenic or myogenic dysfunction. As there is currently no cure for DUA and no way to restore the ability of the detrusor muscle to contract, management of DUA in women is mostly focused on effective bladder drainage by urinary catheterization. Clean intermittent catheterization is the gold standard for bladder drainage however for a variety of reasons, women with DUA often are managed with indwelling urethral catheter or suprapubic tube. Medications, sacral neuromodulation, and the inFlow urinary prosthesis are also treatment alternatives or additions to catheterization. Novel therapies using stem cells and gene therapy are also under investigation for the treatment of DUA and UAB.

CONCLUSIONS

DUA is likely more prevalent than recognized and undertreated in women. It is vital that further research in treatment options beyond catheterization be developed for these patients to offer patients a variety of treatment options.