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The regions of the supraspinal network that controls urinary bladder behavior are well known, but little is known about their interconnections. We tested the feasibility of using physiophysiological interaction to explore the effective connections of the network and to seek disease-related differences in connectivity. This was a secondary analysis of fMRI data obtained from women aged 26-85 years, 11 with urge urinary incontinence and 10 with normal bladder function. In each subject, fMRI BOLD images were obtained during a period with full bladder and strong bladder sensation (without detrusor overactivity) while repeatedly infusing and withdrawing a small amount of liquid in and out of the bladder. Regions of interest included right insula (RI) and anterior cingulate gyrus (ACG), both consistently involved in bladder control. Other regions effectively connected to them were identified by significant correlation between their fMRI signal and the interaction RIxACG. Among normal subjects, many regions involved in bladder control were effectively connected with RI/ACG, including frontotemporal and sensorimotor cortex, forebrain, midbrain and pontine regions. The sign of the correlation with RIxACG was near-uniformly positive, perhaps suggesting mainly inhibitory connections. Among urge-incontinent subjects, the effective connectivity was shifted to a parieto-temporal complex, while the sign of the correlation was predominantly negative, perhaps consistent with excitation (recruitment) of accessory pathways in an attempt to maintain bladder control. Thus, physiophysiological interaction yields potentially important information about the connectivity of the bladder control network and its changes in disease.
The artificial fluorinated group of compounds polyfluoroalkyl chemicals (PFCs) has been applied extensively in daily life for decades, and is present in food, drinking water, and indoor dust. The nephrotoxicity of PFCs has been widely studied for its characteristics of being mainly excreted through passing urine and affecting urodynamics. This work aimed to investigate the relationship between PFCs and the occurrence of urge urinary incontinence (UUI) in the United States (US) population.
Urinary incontinence (UI) has been identified as a World Health Organization health priority. In particular, urge UI (UUI) refers to urine leakage associated with a sudden and compelling desire to void urine. It affects quality of life more than other kinds of UI, but it is not always treated adequately. For these reasons, this study aimed to evaluate the effectiveness of conservative treatment practices to counteract UUI in women aged 40-65 years old.
The aim of this debate article is to discuss whether effective treatments are available for mixed urinary incontinence (MUI). Because patients with MUI have both stress and urgency urinary incontinence (SUI and UUI) episodes and current treatment guidelines currently recommend treating the predominant symptom first, this article presents standard and emerging treatments for both SUI and UUI before discussing how well these treatments meet the medical needs of patients with MUI. Standard treatments presented include noninvasive options such as lifestyle changes and pelvic floor exercises, pharmacological agents, and surgery. Treatment of all three types of urinary incontinence (UI) is usually initiated with noninvasive options, after which treatment options diverge based on UI subtype. Multiple pharmacological agents have been developed for the treatment of UUI and overactive bladder, whereas surgery remains the standard option for SUI and stress-predominant MUI. The divide between UUI and SUI options seems to be propagated in emerging treatments, with most novel pharmacological agents still targeting UUI and even having SUI and stress-predominant MUI as exclusion criteria for participation in clinical trials. Considering that current treatment options focus almost exclusively on treating the predominant symptom of MUI and that emerging pharmacological treatments exclude patients with stress-predominant MUI during the development phase, effective treatments for MUI are lacking both in standard and emerging practice. Ideally, agents with dual mechanisms of action could provide symptom benefit for both the stress and urgency components of MUI.
A good understanding of the factors involved in female urinary incontinence is essential for the therapeutic management of incontinent women. Urinary stress incontinence involves three variables which participate in the pressure equilibrium during effort: mobility of the urethrovesical junction, urethral resistance and the intensity of effort. The most appropriate treatment for each patient can only be selected by investigating all three of these factors and by determining their respective roles in incontinence. Urge incontinence is also multifactorial, but, very often, no cause can be found on the aetiological assessment, leading to the diagnosis of idiopathic instability. The factors of detrusor motor instability are discussed and their aetiological treatment is proposed.
Women with urinary incontinence incur an increased risk of elevated postvoid residual (PVR) volume and impaired voiding efficiency (i.e., voided percentage (Void%)), but the clinical significance of these parameters remains poorly described. Further characterization of PVR and voiding efficiency may thus be useful in refining the evaluation and management of urinary incontinence. This study aims to explore possible circadian variations in PVR and Void% in older women with stress (SUI), urge (UUI) and mixed urinary incontinence (MUI).
The study reports a single center experience with surgical management of female pelvic organ prolapse (POP) with and without urinary incontinence.Between January 2006 and July 2016, 93 consecutive patients with anterior and/or apical symptomatic POP underwent abdominal sacrocolpopexy (ASC) or laparoscopic sacrocolpopexy (LSC) or pubovaginal cystocele sling (PCS); 25 patients had concomitant stress urinary incontinence (SUI). Subjective outcome was assessed by the Pelvic Floor Impact Questionnaire (short form) (PFIQ-7) investigating bladder, bowel and vaginal functions, sexual activity, and daily life. Objective outcomes included the POP anatomic correction by Baden Walker HWS classification, urinary tract infection (UTI) rates, urge urinary incontinence (UUI), and SUI rates. Data were prospectively collected.Forty-three patients underwent PCS, 29 ASC, and 21 LSC. Mean follow-up was 54.88 ± 33.1, 28.89 ± 23.5, and 16.8 ± 11.3 months for PCS, ASC, and LSC, respectively. POP recurrence occurred in 10.5%, 7.5%, and 0% while de novo (ie, in untreated compartment/s) POP occurred in 15.8%, 7.4%, and 4.8% of patients who have undergone PCS, ASC, and LSC, respectively. Kaplan-Meier estimates of POP-free survival showed no difference among the 3 procedures. All procedures significantly reduced PFIQ-7 scores improving quality of life and the rates of recurrent UTIs and concomitant UUI. PCS cured all cases with concomitant SUI; de novo SUI occurred only in 7.4% and 4.8% of patients who have undergone ASC and LSC, respectively. Mean surgical time was significantly shorter for PCS compared to ASC and LSC (P = .0001), and for ASC compared to LSC (P = .004); there was no difference in postoperative pain and hospital stay. Compared to ASC/LSC, PCS involved a higher rate (27.9% vs 6%; P = .01) of minor complications, mainly transient urinary retention, and a lower rate (0% vs 8%; P = .06) of complications requiring surgery.In this single center experience, PCS was not only provided similar subjective and objective results than ASC and LSC but also able to correct concomitant SUI without causing de novo SUI and was safer than other 2 techniques, in female POP repair.
Sacral neuromodulation (SNM) is a guideline-recommended treatment for voiding dysfunction including urgency, urge incontinence, and nonobstructive retention as well as fecal incontinence. The Axonics® System is a miniaturized, rechargeable SNM system designed to provide therapy for at least 15 years, which is expected to significantly reduce revision surgeries as it will not require replacement as frequently as the non-rechargeable SNM system. The ARTISAN-SNM study is a pivotal study designed to treat patients with urinary urgency incontinence (UUI). Clinical results at 1-year are presented.
A study was done on the prevalence, risk factors, and treatment-seeking behavior of elderly women with urinary incontinence (UI) residing in Kochi Corporation, Kerala, India. The community-based cross-sectional study was done in Kochi on 525 elderly women aged 60 years and above, selected by cluster random sampling, after getting consent, using a questionnaire. The overall prevalence of UI was found to be 64% (95% confidence interval (CI) 59.5-67.6). The most common type of UI was found to be the urge type of incontinence (38.3%, 95% CI, 34.14-42.45). Chronic cough (odds ratio [OR] 1.754, 95% 1.170-2.631), chronic constipation (OR: 1.563, 95% CI: 1.030-2.373), obesity (OR: 1.591, 95% CI: 1.110-2.280), diabetes (OR: 1.517, 95% CI: 1.036-2.222), and taking medications for diabetes and hypertension (OR: 1.476, 95% 1.008-2.163) were found to be risk factors of UI. Multiparity (OR: 1.757, 95% CI: 1.073-2.876), delivery at home (OR: 1.761, 95% CI: 1.205-2.575), undergoing any pelvic surgery (OR: 1.504, 95% CI: 1.052-2.150) were the gynecological and obstetric factors associated with UI.
Urge Urinary Incontinence: "a sudden and uncontrollable desire to void which is impossible to defer" is extremely common and considered the most bothersome of lower urinary tract conditions. Current treatments rely on pharmacological, neuromodulatory, and neurotoxicological approaches to manage the disorder, by reducing the excitability of the bladder muscle. However, some patients remain refractory to treatment. An alternative approach would be to temporarily suppress activity of the micturition control circuitry at the time of need i.e., urgency. In this study we investigated, in a rat model, the utility of high frequency pelvic nerve stimulation to produce a rapid onset, reversible suppression of voiding. In urethane-anesthetized rats periodic voiding was induced by continuous infusion of saline into the bladder whilst recording bladder pressure and electrical activity from the external urethral sphincter (EUS). High frequency (1-3 kHz), sinusoidal pelvic nerve stimulation initiated at the onset of the sharp rise in bladder pressure signaling an imminent void aborted the detrusor contraction. Urine output was suppressed and tone in the EUS increased. Stimulating the right or left nerve was equally effective. The effect was rapid in onset, reversible, and reproducible and evoked only minimal "off target" side effects on blood pressure, heart rate, respiration, uterine pressure, or rectal pressure. Transient contraction of abdominal wall was observed in some animals. Stimulation applied during the filling phase evoked a small, transient rise in bladder pressure and increased tonic activity in the EUS, but no urine output. Suppression of micturition persisted after section of the contralateral pelvic nerve or after ligation of the nerve distal to the electrode cuff on the ipsilateral side. We conclude that high frequency pelvic nerve stimulation initiated at the onset of an imminent void provides a potential means to control urinary continence.
Overactive bladder (OAB) is a highly prevalent symptom complex characterised by symptoms of urinary urgency, increased frequency, nocturia, with or without urge incontinence; in the absence of proven infection or other obvious pathology. The underlying pathophysiology of idiopathic OAB is not clearly known and the existence of several phenotypes has been proposed. Current diagnostic approaches are based on discordant measures, suffer from subjectivity and are incapable of detecting the proposed OAB phenotypes. In this study, cluster analysis was used as an objective approach for phenotyping participants based on their OAB characteristic symptoms and led to the identification of a low OAB symptomatic score group (cluster 1) and a high OAB symptomatic score group (cluster 2). Furthermore, the ability of several potential OAB urinary biomarkers including ATP, ACh, nitrite, MCP-1 and IL-5 and participants' confounders, age and gender, in predicting the identified high OAB symptomatic score group was assessed. A combination of urinary ATP and IL-5 plus age and gender was shown to have clinically acceptable and improved diagnostic accuracy compared to urodynamically-observed detrusor overactivity. Therefore, this study provides the foundation for the development of novel non-invasive diagnostic tools for OAB phenotypes that may lead to personalised treatment.
Over 50% of women with detrusor overactivity (DO), who do not respond to therapy have been shown to have bacteriuria, which may stimulate the release of inflammatory cytokines than can enhance nerve signalling, leading to symptoms of urgency. This study made use of a consecutive series of urine samples collected from women with refractory DO, who participated in a clinical trial of rotating antibiotic therapy. The aim was to determine the effect of bacteriuria and antibiotic treatment on the levels of urinary cytokines, and to correlate the cytokine concentration with patient outcome measures relating to urgency or urge incontinence. The urinary cytokines chosen were IL-1α, IL-1 receptor antagonist, IL-4, IL-6, IL-8, IL-10, CXCL10 (IP-10), MCP-1 and TNF-α. The presence of bacteriuria stimulated a significant increase in the concentrations of IL-1α (P 0.0216), IL-1 receptor antagonist (P 0.0264), IL-6 (P 0.0003), IL-8 (P 0.0043) and CXCL-10 (P 0.009). Antibiotic treatment significantly attenuated the release of IL-1α (P 0.005), IL-6 (P 0.0027), IL-8 (P 0.0001), IL-10 (P 0.049), and CXCL-10 (P 0.042), i.e. the response to the presence of bacteria was less in the antibiotic treated patients. Across the 26 weeks of the trial, antibiotic treatment reduced the concentration of five of the nine cytokines measured (IL-1α, IL-6, IL-8, IL-10 and CXCL-10); this did not reach significance at every time point. In antibiotic treated patients, the urinary concentration of CXCL-10 correlated positively with four of the six measures of urgency. This study has shown that cytokines associated with activation of the innate immune system (e.g. cytokines chemotactic for or activators of macrophages and neutrophils) are reduced by antibiotic therapy in women with refractory DO. Antibiotic therapy is also associated with symptom improvement in these women, therefore the inflammatory response may have a role in the aetiology of refractory DO.
Pelvic floor disorders (PFDs) including urinary incontinence, faecal incontinence and pelvic organ prolapse are common debilitating conditions among women in high-income countries. However, PFDs in women in low/middle-income countries (LMICs) have not been studied extensively. We aim to conduct a systematic review and meta-analysis of the available literature to determine the prevalence of, and/or risk factors for, PFDs in women in LMIC.
Overactive bladder (OAB) is a symptom syndrome defined by the International Continence Society (ICS) as 'the presence of urinary urgency (both daytime and nighttime), usually accompanied by increased frequency and nocturia with or without urge urinary incontinence in the absence of a urinary tract infection or other obvious pathology'. Clinical studies indicate that acupuncture could reduce micturition over 24 h, urgency episodes over 24 h, and improve quality of life among people with OAB. This systematic review protocol details the proposed methods for evaluating the effectiveness and safety of acupuncture for OAB.
Several studies described post-operative irritative symptoms after laser enucleation of prostate, sometimes associated with urge incontinence, probably linked to laser-induced prostatic capsule irritation, and potential for lower urinary tract infections We aimed to evaluate the efficacy of a suppository based on Phenolmicin P3 and Bosexil (Mictalase®) in control of irritative symptoms in patients undergoing thulium laser enucleation of prostate (ThuLEP).
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