Eric Chieh-Lung Chou

Incomplete Bladder Emptying in Patients With Stroke: Is Detrusor External Sphincter Dyssynergia a Potential Cause?

OBJECTIVES To delineate the frequency, clinical risk factors, and urodynamic mechanisms of incomplete bladder emptying (IBE) among patients with recent stroke. DESIGN Retrospective study. SETTING Inpatient setting in the rehabilitation ward of a university hospital. PARTICIPANTS All patients with acute stroke admitted for rehabilitation between January and December 2005, excluding those with a history of lower-urinary tract symptoms and urologic diseases. Eighty-two patients (42 women and 40 men; mean age, 65.5 y) were included. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We measured postvoid residual (PVRs) by catheterization or by using an ultrasonic bladder scanner. Twenty-five patients (30.5%) had IBE with PVRs greater than 100 mL on 2 consecutive days. Patients with IBE were evaluated by a urologist and subsequently underwent urodynamic studies. RESULTS The presence of IBE was significantly associated with urinary tract infection (P<.001) and aphasia (P=.046). The presence of IBE was not related to sex, stroke location, nature of stroke (hemorrhagic or ischemic), history of diabetes mellitus, or previous stroke. Urodynamic studies done on 22 patients with IBE revealed acontractile detrusor in 8 patients (36%) and detrusor underactivity in 3 (14%). Eleven patients (50%) had detrusor-external sphincter dyssynergia (DESD) combined with normative detrusor function (5 patients) or detrusor hyperactivity (6 patients); all but 1 of these patients had a supratentorial lesion. The presence of DESD was associated with a longer onset-to-evaluation interval (P=.018) [corrected] and spasticity of the stroke-affected lower limb (P=.02). [corrected] Diabetes mellitus was associated with the presence of acontractile detrusor or detrusor underactivity (P=.03). CONCLUSIONS IBE is common among patients with stroke and is caused by decreased detrusor contractility or DESD. Spasticity of the external urethral sphincter is a possible pathophysiologic mechanism of DESD.

Urodynamic Characteristics of Mixed Urinary Incontinence and Idiopathic Urge Urinary Incontinence

To evaluate and compare the clinical and urodynamic findings in patients with either mixed urinary incontinence (MUI) or simple urge urinary incontinence (UUI).

Female voiding postures and their effects on micturition

Introduction and hypothesisThis study investigated the effect of sitting and non-sitting postures on uroflowmetric parameters and postvoid residual urine (PVR) and womens preferred voiding posture.MethodsFemale university students (N = 45) voided on a modified sitting-type toilet in three postures: sitting, semi-squatting, and crouching over. Data on uroflowmetric measures were collected using a weight transducer urodynamic device and PVR was estimated by transabdominal ultrasound.ResultsVoiding in the three postures did not differ in terms of PVR and five of six uroflowmetric outcomes. However, “delay time to void” was significantly longer while semi-squatting than while sitting and crouching over. Furthermore, 51.1% of women had bell-shaped urinary flow curves while sitting, whereas only 22.2% and 17.8% did while semi-squatting and crouching over, respectively. Most women (88.9%) preferred a non-sitting posture when using a public sitting-type toilet.ConclusionsWomens preferred non-sitting void posture on public sitting-type toilet should be a concern.

The evaluation of bladder symptoms in patients with lumbar compression disorders who have undergone decompressive surgery.

Study Design. Prospective cohort study. Objective. We study the relationship between the degree of dural sac compression, the prevalence of lower urinary tract symptoms, and the effect of surgical decompression in patients with lumbar spinal canal compression using the American Urological Association Symptom Score (AUAss). Summary of Background Data. Patients with lumbar spinal canal compression not only experienced leg neuropathy but also lower urinary tract symptoms. There are few reports concerning the prevalence of bladder symptoms and the effect of decompression on urinary symptoms. Methods. We enrolled 245 patients, who were admitted for decompression of lumbar spinal canal compression, using the AUAss) On the basis of the score, patients were divided into 2 groups: those with significant neurologic bladder symptoms (high AUAss), and those without significant symptoms (low AUAss). The narrowest anteroposterior diameter of the dural sac at the corresponding level of decompression on axial magnetic resonance imaging (MRI) was measured for both groups. The Oswestry Disability Index and AUAss were compared before and after decompressive surgery. The urodynamic change in the group of high AUAss after surgery was analyzed. Results. A total of 67 patients (27%) had significant lower urinary tract symptoms in our study group. The mean/median number of levels decompressed was 1.5/1 in high AUAss and 1.8/2 in low AUAss group. Decompressive surgery had beneficial effect on both the AUAss and Oswestry Disability Index in both groups. The postvoid residual urine volume was significantly reduced after surgical decompression. The narrowest diameter of dural sac on MRI has correlation with AUAss. Conclusion. We found that 27% patients with lumbar spinal compression disorders had lower urinary tract symptoms; the anteroposterior diameter of dural sac measured on axial MRI is correlated with the lower urinary tract symptoms. After the decompressive surgery, the most sensitive indicator of bladder dysfunction was subjective symptoms and postvoid residual voiding volume.

Botulinum toxin A for the Treatment of Overactive Bladder

The standard treatment for overactive bladder starts with patient education and behavior therapies, followed by antimuscarinic agents. For patients with urgency urinary incontinence refractory to antimuscarinic therapy, currently both American Urological Association (AUA) and European Association of Urology (EAU) guidelines suggested that intravesical injection of botulinum toxin A should be offered. The mechanism of botulinum toxin A includes inhibition of vesicular release of neurotransmitters and the axonal expression of capsaicin and purinergic receptors in the suburothelium, as well as attenuation of central sensitization. Multiple randomized, placebo-controlled trials demonstrated that botulinum toxin A to be an effective treatment for patients with refractory idiopathic or neurogenic detrusor overactivity. The urinary incontinence episodes, maximum cystometric capacity, and maximum detrusor pressure were improved greater by botulinum toxin A compared to placebo. The adverse effects of botulinum toxin A, such as urinary retention and urinary tract infection, were primarily localized to the lower urinary tract. Therefore, botulinum toxin A offers an effective treatment option for patients with refractory overactive bladder.

Effects of electroacupuncture on recent stroke inpatients with incomplete bladder emptying: a preliminary study

Background Incomplete bladder emptying (IBE) is defined as having a postvoid residual (PVR) urine volume greater than 100 mL for 2 consecutive days. IBE is common in stroke patients and could necessitate indwelling or intermittent catheterization. The condition is correlated with urinary tract infections, which could impede rehabilitation progress and increase medical costs. Treatment for patients with IBE includes bladder retraining, biofeedback, medication, and botulinum toxin injection, but none of these interventions are completely effective. Methods All patients with acute stroke who were admitted to the rehabilitation ward between August 2010 and April 2011 were included in the study and their PVR urine volume was checked. Electroacupuncture (EA; 1 Hz, 15 minutes) was performed on the acupoints Sanyinjiao (SP6), Ciliao (BL32), and Pangguangshu (BL28) of stroke patients with IBE for a total of ten treatments (five times a week for 2 weeks). Bladder diaries, which included the spontaneous voiding and PVR urine volumes, were recorded during the course of treatment. Results The presence of IBE was not related to sex, history of diabetes mellitus, stroke type (hemorrhagic or ischemic), or stroke location (P > 0.05). Among the 49 patients in the study, nine (18%) had IBE, and seven of the stroke patients with IBE were treated with EA. Increased spontaneous voiding volume and decreased PVR urine volume were noted after ten sessions of EA. Conclusion EA may have beneficial effects on stroke survivors with IBE, thereby making it a potential safe modality with which to improve urinary function.

Superficial transitional cell carcinoma of the ureteral orifice: higher risk of developing subsequent upper urinary tract tumors.

Aim:  Reports specifically addressing transitional cell carcinoma (TCC) of the ureteral orifice are scarce. This paper presents our experiences of such tumors, including the characteristics of the disease and the incidence of subsequent upper urinary tract recurrence.

Women urinate in the standing position do not increase post-void residual urine volumes.

The effects of standing while voiding have seldom been investigated in women. We evaluate urodynamic parameters of voiding while standing in healthy women using uroflowmetry and post‐void residual urine volume assessment. Results are compared with crouching and sitting.

Spontaneous ureteral rupture and review of the literature.

INTRODUCTION Spontaneous ureteral rupture is defined as non-traumatic urinary leakage from the ureter. This is a diagnosis that, although uncommon, is important for emergency physicians to know about. The literature is relatively sparse. MATERIALS AND METHODS This was a retrospective review of patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed by radiography (computed tomography or intravenous urogram) with spontaneous ureteral rupture. These cases all showed extravasation of the contrast outside the excretory system. We evaluated underlying causes, diagnostic and therapeutic procedures, and outcomes. RESULTS There were 9 men and 9 women with a median age of 59 years (range, 22-82 years). In 56% of patients, a ureteral stone was the cause; in 17% of, a ureteral stricture; in 1 patient, a ureteral tumor; and in the remaining 22%, no cause was identified. In 13 patients (72.2%), primary ureteroscopy to place D-J stents was performed. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). The other 5 patients (27.8%) were managed conservatively with antibiotic treatment and the outcome was good. CONCLUSIONS Ureteral stones most commonly cause spontaneous ureteral rupture. In our experience, most patients received ureteroscopy and Double-J stenting. Conservative management with antibiotics also had good outcomes. Most patients had sudden onset of abdominal or flank pain. Spontaneous ureteral rupture should be kept in the differential diagnosis of patients with acute abdominal or flank pain in the emergency department.

Urinating in the Standing Position: A Feasible Alternative for Elderly Women With Knee Osteoarthritis

PURPOSE Urinating while standing is a possible alternative for elderly women with knee osteoarthritis when a sitting toilet is unavailable. We evaluated uroflowmetric characteristics and post-void residual urine volume in elderly women with knee osteoarthritis who urinated while standing. MATERIALS AND METHODS We recruited 21 women with a mean±SD age of 65.0±4.6 years who had a knee osteoarthritis Lequesne index score of at least 6 points and were unable to maintain or found it difficult to stand up from a squat or crouch. Participants used a homemade auxiliary appliance to collect urine and drain it forward while stand voiding. Uroflowmetric data, including voided volume, and maximal and average flow rates, were recorded. Post-void residual urine volume was detected using an ultrasound bladder scanner. Participants completed a questionnaire to evaluate their attitude toward stand voiding and using the auxiliary device. RESULTS Maximal and average flow rates, and voided and post-void residual urine volumes were not statistically different while sitting and standing. No learning curve was noted for stand voiding. Uroflowmetry patterns while standing were smooth. Of the 21 participants 17 (81%) experienced no difficulty while stand voiding. All expressed willingness to urinate while standing position if they did not have access to a satisfactorily clean toilet seat. CONCLUSIONS Urinating while standing is a feasible option for elderly women with knee osteoarthritis who have difficulty crouching or squatting to void in public restrooms.