Flavia Gregorini

Acute Spinal Cord Injury—Do Ambulatory Patients Need Urodynamic Investigations?

PURPOSE We compared the urodynamic parameters of ambulatory vs nonambulatory acute spinal cord injured patients. MATERIALS AND METHODS A total of 27 women and 33 men (mean age 58 years) with neurogenic lower urinary tract dysfunction due to acute spinal cord injury (duration of injury less than 40 days) were prospectively evaluated. The patients were dichotomized according to the mobility for moderate distances subscale of the SCIM (Spinal Cord Independence Measure) version III into ambulatory (score of 3 or greater) and nonambulatory (score less than 3). Videourodynamic parameters including maximum detrusor pressure during the storage phase, bladder compliance, detrusor overactivity, detrusor external sphincter dyssynergia and vesicoureterorenal reflux were compared between the groups. RESULTS Of the 60 patients with acute spinal cord injury 17 were ambulatory and 43 were nonambulatory. Mean ± SD duration of injury at urodynamic investigation was 30 ± 8 days. The lesion level was cervical in 14 patients, thoracic in 28 and lumbar/sacral in 18. Comparing unfavorable urodynamic parameters, no significant differences were found between ambulatory vs nonambulatory patients in terms of a high pressure system during the storage phase (29% vs 33%, p = 0.81), a low compliance bladder (12% vs 7%, p = 0.54), detrusor overactivity (24% vs 47%, p = 0.1), detrusor external sphincter dyssynergia (18% vs 21%, p = 0.77) and vesicoureterorenal reflux (0% vs 5%, p = 0.36). CONCLUSIONS Ambulatory and nonambulatory patients with acute spinal cord injury have a similar risk of unfavorable urodynamic measures. Thus, we strongly recommend the same neurourological assessment including urodynamic investigations in all acute spinal cord injury patients independent of the ability to walk.

Neurogenic Lower Urinary Tract Dysfunction—Do We Need Same Session Repeat Urodynamic Investigations?

PURPOSE We investigated whether same session repeat urodynamic investigations are needed in patients with neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS A consecutive series of 226 patients with neurogenic lower urinary tract dysfunction who underwent same session repeat urodynamic investigation was prospectively investigated at a single university spinal cord injury center. Urodynamics were done according to the good urodynamic practices recommended by the International Continence Society. All 226 patients underwent same session repeat consecutive filling cystometry and 88 also underwent pressure flow studies if they could void spontaneously. Repeatability of the 2 measurements was assessed using the Bland and Altman 95% limits of agreement, and the κ statistic. RESULTS Mean age of the 226 patients enrolled was 52 years (range 18 to 90). Of the patients 94 (42%) were women and 132 were (58%) men. Detrusor overactivity repeatability was excellent between the 2 urodynamic investigations (κ=0.87, 95% CI 0.80-0.94). For all other urodynamic parameters assessed there were wide 95% limits of agreement for differences in the parameters, indicating poor repeatability. CONCLUSIONS In same session repeat urodynamic investigations of patients with neurogenic lower urinary tract dysfunction detrusor overactivity demonstrates excellent repeatability but all other urodynamic parameters show insufficient agreement. Thus, we strongly recommend that clinical decision making not be based on a single urodynamic investigation since repeat measurements may yield completely different results.

Supraspinal Control of Urine Storage and Micturition in Men—An fMRI Study

Despite the crucial role of the brain in the control of the human lower urinary tract, little is known about the supraspinal mechanisms regulating micturition. To investigate the central regulatory mechanisms activated during micturition initiation and actual micturition, we used an alternating sequence of micturition imitation/imagination, micturition initiation, and actual micturition in 22 healthy males undergoing functional magnetic resonance imaging. Subjects able to micturate (voiders) showed the most prominent supraspinal activity during the final phase of micturition initiation whereas actual micturition was associated with significantly less such activity. Initiation of micturition in voiders induced significant activity in the brainstem (periaqueductal gray, pons), insula, thalamus, prefrontal cortex, parietal operculum and cingulate cortex with significant functional connectivity between the forebrain and parietal operculum. Subjects unable to micturate (nonvoiders) showed less robust activation during initiation of micturition, with activity in the forebrain and brainstem particularly lacking. Our findings suggest that micturition is controlled by a specific supraspinal network which is essential for the voluntary initiation of micturition. Once this network triggers the bulbospinal micturition reflex via brainstem centers, micturition continues automatically without further supraspinal input. Unsuccessful micturition is characterized by a failure to activate the periaqueductal gray and pons during initiation.

Sensory Evoked Potentials of the Human Lower Urinary Tract

PURPOSE We investigated the feasibility and reliability of recording sensory evoked potentials after lower urinary tract electrical stimulation. Sensory evoked potentials might reveal improved insights into afferent processing in specific locations of the human lower urinary tract. MATERIALS AND METHODS Electrical stimulation (0.5 and 3 Hz) was applied to the bladder dome and trigone, and the proximal and distal urethra using a transurethral catheter. Cortical sensory evoked potentials were recorded at the Cz electrode with reference to the Fz electrode. All measurements were repeated 3 times for reliability assessment using the ICC. RESULTS Ten healthy female subjects with a mean ± SD age of 23 ± 4 years and a mean height of 168 ± 6 cm were included in the study. The most prominent, consistent sensory evoked potential landmark across different locations was the first negative peak. In all subjects after 0.5 Hz stimulation, the first negative peak was reliably recorded at a mean of 128.8 ± 23.8, 141.9 ± 51.5, 133.1 ± 32.1 and 132.5 ± 33.6 milliseconds (ICC 0.88, 0.83, 0.90 and 0.81) at the bladder dome, trigone, proximal and distal urethra, respectively. After 3 Hz stimulation, no reliable sensory evoked potentials could be recorded. CONCLUSIONS Sensory evoked potentials can be reliably recorded from different lower urinary tract locations after 0.5 Hz stimulation with a characteristic negativity at about 130 milliseconds. These latencies are compatible with a conduction velocity in the range of 3 to 10 m per second, corresponding to transmission by A-δ fibers. The inability to retrieve reliable responses at 3 Hz stimulation might potentially be related to less involvement of fast conduction fibers, ie A-β, in afferent sensation along the human lower urinary tract. The value of a more distinct diagnosis of sensory sensation in lower urinary tract disorders must be evaluated in further studies.

Sensory evoked potentials of the bladder and urethra in middle-aged women: the effect of age.

To investigate feasibility, reproducibility and age dependency of sensory evoked cortical potentials (SEPs) after electrical stimulation of different locations in the lower urinary tract (LUT) in a cohort of middle‐aged healthy women.

External Urethral Sphincter Pressure Measurement: An Accurate Method for the Diagnosis of Detrusor External Sphincter Dyssynergia?

Background Combined pelvic floor electromyography (EMG) and videocystourethrography (VCUG) during urodynamic investigation are the most acceptable and widely agreed methods for diagnosing detrusor external sphincter dyssynergia (DESD). Theoretically, external urethral sphincter pressure (EUSP) measurement would provide enough information for the diagnosis of DESD and could simplify the urodynamic investigation replacing combined pelvic floor EMG and VCUG. Thus, we evaluated the diagnostic accuracy of EUSP measurement for DESD. Patients & Methods A consecutive series of 72 patients (36 women, 36 men) with neurogenic lower urinary tract dysfunction able to void spontaneously was prospectively evaluated at a single university spinal cord injury center. Diagnosis of DESD using EUSP measurement (index test) versus combined pelvic floor EMG and VCUG (reference standard) was assessed according to the recommendations of the Standards for Reporting of Diagnostic Accuracy Initiative. Results Using EUSP measurement (index test) and combined pelvic floor EMG and VCUR (reference standard), DESD was diagnosed in 10 (14%) and in 41 (57%) patients, respectively. More than half of the patients presented discordant diagnosis between the index test and the reference standard. Among 41 patients with DESD diagnosed by combined pelvic floor EMG and VCUR, EUSP measurement identified only 6 patients. EUSP measurement had a sensitivity of 15% (95% CI 5%–25%), specificity of 87% (95% CI 76%–98%), positive predictive value of 60% (95% CI 30%–90%), and negative predictive value of 56% (95% CI 44%–68%) for the diagnosis of DESD. Conclusions For diagnosis of DESD, EUSP measurement is inaccurate and cannot replace combined pelvic floor EMG and VCUR.

Is there a direct antimicrobial effect of botulinum neurotoxin type A

Study Type – Therapy (case series)

Sensory function assessment of the human male lower urinary tract using current perception thresholds

To evaluate the feasibility and reliability of current perception threshold (CPT) measurement for sensory assessment of distinct locations in the male lower urinary tract (LUT).