Kosaku Yasuda

Micturitional disturbance after acute hemispheric stroke: analysis of the lesion site by CT and MRI

Micturitional histories and urodynamic studies were performed in 72 acute hemispheric stroke patients. Within 3 months from the onset, 53% of the patients had urinary symptoms including irritative as well as obstructive, and the most common symptom was nocturnal urinary frequency in 36%, which was followed by urge urinary incontinence in 29% and difficulty of voiding in 25% of the patients. We found a correlation between micturitional disturbance with hemiparesis (p <0.05) and not with hemianopsia (p <0.05). Micturitional disturbance was more common in lesions of the frontal lobe (p <0.05) than in those of the occipital lobe. Brain CT or MRI in symptomatic patients showed lesions of anterior and medial surface of the frontal lobe, anterior edge of the paraventricular white matter, genu of the internal capsule and large lesions of putamen or thalamus. Urodynamic studies of 22 symptomatic patients revealed various findings in 91% of them, including detrusor hyperreflexia in 68%, detrusor-sphincter dyssynergia (DSD) in 14% and uninhibited sphincter relaxation in 36%. Patients with urinary retention had atonic cystometrogram and DSD. Detrusor hyperreflexia was noted in lesions of the frontal lobe as well as the basal ganglia, uninhibited sphincter relaxation in the frontal lobe, and detrusor-sphincter dyssynergia common in the basal ganglia. Above findings seem to indicate that anteromedial frontal lobe and its descending pathway, and the basal ganglia seem to be mainly responsible for supranuclear types of pelvic and pudendal nerve dysfunction in our patients with stroke.

PELVIC FLOOR ELECTRICAL STIMULATION IN THE TREATMENT OF STRESS INCONTINENCE: AN INVESTIGATIONAL STUDY AND A PLACEBO CONTROLLED DOUBLE-BLIND TRIAL

PURPOSEnWe designed an investigational study and a placebo controlled, double-blind study to evaluate the usefulness of electrical pelvic stimulation in stress incontinence.nnnMATERIALS AND METHODSnWe studied 44 patients with stress incontinence (six men and 38 women, age 63 +/- 13), including 9 patients in the investigational study and 35 in the double-blind study. We used 50 Hz. square waves of 1 ms. pulse duration for stimulation. A vaginal electrode was used in women and an anal electrode in men. Urethral pressure profile before, during and after 15-minute stimulation was measured in the investigational study. In the double-blind trial an active device and a dummy device were used, and efficacy was judged from patient impressions, records in frequency/volume chart, results of 1-hour pad test and urodynamic parameters after 4-week treatment.nnnRESULTSnIn the investigational study maximum urethral closure pressure (mean plus or minus standard deviation) before, during and after stimulation was 44.4 +/- 17.5, 64.5 +/- 28.8 and 46.8 +/- 25.6 cm. water, respectively. This parameter significantly increased (p = 0.0275) during stimulation. In the double-blind trial patient impressions were good in 60% of the active device group and 8% of the dummy device group (p = 0.0051). For the pad test significant improvement was noted in the active device group (p = 0.0100). Cure rate was 45% in the active device group and 7.7% in the dummy device group. There were significantly more cured or improved patients for frequency of leakage (p = 0.0196) and pad test (p = 0.0100).nnnCONCLUSIONSnElectrical stimulation is effective for the treatment of stress incontinence.

Micturitional disturbance and the pontine tegmental lesion: urodynamic and MRI analyses of vascular cases

Micturitional histories were taken from 39 patients with acute brainstem stroke. Within 3 months from onset, 49% had irritative as well as obstructive urinary symptoms, the most common being voiding difficulty and nocturnal urinary frequency in 28%, followed by urinary retention in 21%. Urodynamic studies of 11 symptomatic patients revealed detrusor hyperreflexia in 73%, low compliance bladder in 9%, atonic cystometrogram in 27%, detrusor-sphincter dyssynergia in 45% and uninhibited sphincter relaxation in 27%. Three asymptomatic patients had normal urodynamic findings. Brain magnetic resonance images of the lesions of the symptomatic patients were concentrated in the dorsolateral pons including pontine reticular nucleus and the reticular formation adjacent to the medial parabrachial nucleus and the locus coeruleus. These regions seem to be mainly responsible for supranuclear types of pelvic and pudendal nerve dysfunction in our patients with brainstem stroke, corresponding to the pontine urinary storage and micturation center reported in animal studies.

Allelic losses on 18q21 are associated with progression and metastasis in human prostate cancer

We analyzed normal/tumor DNA pairs obtained from 46 patients with prostate cancers (stage B, 16 cases; C, 10 cases; D1, 4 cases; and endocrine therapy‐resistant cancer‐death, 16 cases) for loss of heterozygosity using 32 microsatellite markers on chromosome 18. Seventeen of the 46 cases (37%) showed loss of heterozygosity (LOH) for at least one locus on the long arm. Detailed deletion mapping in these tumors identified a distinct commonly deleted region within a 5‐cM interval on 18q21.1. There was a statistical correlation between the frequency of LOH on 18q and clinical stage (χ2 = 12.3; P = 0.0064). LOH on 18q was observed more frequently in Stage D1 cases (4/4; 100%) than in Stage B+C cases (5/26; 19%; P = 0.0046, Fishers exact test). In 8 of 9 (89%) cancer‐death patients from whom DNAs were available from both primary and metastatic tumors, the primary tumors had either no detectable abnormality of chromosome 18 or the region involving loss of heterozygosity was limited while the metastatic foci showed more frequent and extended allelic losses on this chromosome. No abnormalities were detected in the DCC and DPC4 genes when their exons were analyzed separately by single strand conformation polymorphism assay. These results suggest that inactivation of one or more putative tumor suppressor genes on 18q21 other than DCC and DPC4 plays an important role in the progression of human prostate cancer. Genes Chromosomes Cancer 20:140–147, 1997.

Micturitional disturbance in progressive supranuclear palsy.

Detailed micturitional histories were taken from nine patients with progressive supranuclear palsy (PSP), and eight of them (89%) had micturitional symptoms including urinary incontinence in seven. Urodynamic studies were performed in six patients and the results were as follows. Three had residual urine of 100 ml on average. Four had detrusor hyperreflexia and one had a low compliance cystometrogram. One had detrusor-sphincter dyssynergia. Motor unit analysis of external sphincter was performed in four patients and two had neurogenic changes. The results were compared with our previous findings in Parkinsons disease and in striato-nigral degeneration (SND), and we found that a severe degree of micturitional disturbance in PSP seems to be as common as in SND, especially in the urinary storage phase, and more frequent than in Parkinsons disease. Supranuclear types of pelvic and pudendal nerve dysfunctions seemed to be mainly responsible for micturitional disturbance in PSP.

PRLTS Gene Alterations in Human Prostate Cancer

Since loss of heterozygosity on 8p22‐p21,3 has been found frequently in prostate cancer, the status of a candidate tumor suppressor gene named PRLTS gene, recently cloned from the same region in some human malignancies, was examined in the present study. DNAs were isolated from 69 Japanese prostate cancer patients (37 localized and 32 cancer‐death cases). Loss of heterozygosity at this gene locus was observed in 15 of 36 (42%) localized prostate cancer patients and 22 of 32 (69%) cancer‐death patients. One cancer‐death patient had a missense mutation, ACG→ATG (Thr→Met) at codon 64 in metastatic tumor tissues of pelvic lymph node and liver, and these tissues showed loss of the homologous allele, indicating that “two‐hit” mutation of the PRLTS gene had occurred in this case. The others did not show any mutation, regardless of the presence or absence of loss of heterozygosity. Although loss of heterozygosity at the PRLTS gene locus is a relatively common abnormality, mutation of this gene is rare in prostate cancer.

Micturitional disturbance in acute disseminated encephalomyelitis (ADEM).

In eleven patients with acute disseminated encephalomyelitis (ADEM), micturitional histories taken during the acute stage revealed that nine were in a state of urinary retention, and the other two had urinary frequency and urge incontinence together with difficulty in voiding. After the follow-up period of 3 to 38 months seven of nine patients with retention became able to urinate, but five of them had difficulty in voiding and four of them developed urinary frequency or urge incontinence. Two patients had urinary retention even after 26 and 38 months from the onset. Ten patients underwent urodynamic studies and disclosed detrusor hyperreflexia in six, low compliance bladder in two, atonic cystometrogram in one and detrusor-sphincter dyssynergia in two patients. Motor unit analysis of the external sphincter revealed polyphasic neurogenic changes is one of four patients. The results were compared with our previous findings in multiple sclerosis (MS), and we found that micturitional disturbance in ADEM seemed to be as common and as severe as in MS. Supranuclear as well as nuclear types of pelvic and pudendal nerve dysfunction seemed to be responsible for micturitional disturbance in our patients with ADEM. Micturitional disturbance seemed to be related to the pyramidal tract involvement, and probably reflecting the severity of spinal cord lesions.

MICTURITIONAL DISTURBANCE IN WERNICKE'S ENCEPHALOPATHY

A 24‐year‐old pregnant woman started to have hyperemesis gravidarum 6 weeks before admission. Four weeks later she had vertigo, diplopia, staggering gait, mild dyspnea, dysphagia, and incontinence of urine. On admission she presented with ophthalmoplegia, ptosis, ataxia, decreased tendon reflex, and memory disturbance. Brain magnetic resonance imaging revealed abnormal intensities in medial thalamic‐hypothalamic regions and the periaqueductal area, and she was diagnosed with Wernickes encephalopathy. Urodynamic studies revealed decreased bladder volume and detrusor hyperreflexia. Six weeks after the administration of 100 mg/day of thiamine, urge incontinence gradually recovered, together with neurological signs. Lesions of the medial thalamic‐hypothalamic area and the periaqueductal gray matter seemed to be mainly responsible for micturitional disturbance in our patient with Wernickes encephalopathy. Neurourol. Urodynam. 16:111–115, 1997.

The location of the paths subserving micturition: studies in patients with cervical myelopathy

Urodynamic studies and neurological examinations were performed on 128 patients with cervical myelopathies including 82 with spondylitic myelopathy and 46 with ossification of the posterior longitudinal ligament (OPLL), investigating the location of the paths subserving micturition in the spinal cord. Accurate history taking revealed micturitional symptoms in 95 patients, including irritative symptoms in 61 and obstructive symptoms in 71. Urinary incontinence was noted in 25 and residual urine of over 100 ml or retention was found in 22. Neurological examination revealed disturbed deep sensation in 55, disturbed superficial sensation in 63 and pyramidal signs (weakness, hyperreflexia of legs and Babinski sign) in 96 patients. Urodynamic studies revealed uninhibited contraction in 61 and detrusor-sphincter dyssynergia in 22 patients. Bladder capacity was smaller in patients with Babinski sign (P < 0.05) and in patients with uninhibited contraction (P < 0.001). Uninhibited contraction was more frequent in patients with all three of the above-mentioned pyramidal signs (P < 0.05). Detrusor-sphincter dyssynergia was more frequent in patients with disturbed deep sensation (P < 0.05) and pyramidal signs (P < 0.05, P < 0.0005). From above results and our previous findings in patients with anterior spinal artery syndrome and with tabes dorsalis, it is concluded that the pathway subserving detrusor function seems to be located mainly in the lateral column of the spinal cord. The descending pathway subserving coordination of bladder and urethral sphincter seems to be located mainly in the lateral column, and its ascending pathway seems to be located in the dorsal column. The path subserving urinary sensation seems to be located mainly in the dorsal column of the spinal cord.

Endoscopic Re-Establishment of Membranous Urethral Disruption

A total of 17 patients with traumatic membranous urethral disruption underwent urethral reconstruction via a core-through technique. Followup was 1 to 8 years (mean 3.7 years) postoperatively, and included 6 weeks with an indwelling catheter, periodic dilation for 6 months and occasional sounding. Within 1 year postoperatively, 6 patients required additional scar incision, including 3 who underwent scar resection. At 1 to 8 years postoperatively 6 patients had complications: 3 had stricture requiring periodic dilation (including 2 who underwent scar incision), while 2 had mild stress incontinence and 1 had nocturnal enuresis. Traumatic impotence was noted in 7 patients but the operation was not the cause in any. This method of endoscopic management was found to be an acceptable alternative to urethroplasty in cases of membranous urethral disruption.