Masaki Tojo

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.

Micturitional Disturbance in Multiple System Atrophy

Abstract: Detailed micturitional histories and urodynamic studies were conducted to investigate the micturitional disturbance in multiple system atrophy (MSA). Eighty‐six patients with MSA comprised of 14 with striatonigral degeneration (SND), 42 with olivopontocerebellar atrophy (OPCA) and 30 with Shy‐Drager syndrome (SDS). The results were as follows. Micturitional symptoms were noted in over 90% of patients with each type of MSA. Dominant symptoms were irritative ones in SND and OPCA, and a combination of irritative and obstructive ones in SDS. Micturitional symptoms in SDS appeared earlier than those in SND or OPCA. The degree of micturitional disturbance was severer in SDS than in SND or OPCA. Micturitional disturbance tended to become worse as the disease progressed. The responsible sites of lesions of micturitional disturbance seemed to be supra‐ as well as infranuclear lesions of the pelvic and pudendal nerves in MSA. Infranuclear lesions were more prominent in SDS than in SND or OPCA. Follow‐up studies of some of the patients with SDS and OPCA suggested that the responsible sites of pelvic nerve lesions changed from supra‐ to infranuclear lesions during the course of disease.

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.

Effects of beta 2-stimulants on contractility and fatigue of canine urethral sphincter.

The effects of beta 2-stimulants [clenbuterol (CB) and terbutaline (TB)] on the contractility of the urethral sphincter of female dogs were studied by measuring intraurethral pressure (IUP) during stimulation of bilateral pudendal nerves. In nine dogs 1, 10 and 100 micrograms/kg. of CB were administered, but no changes in IUP were observed. In the other 33 dogs, sphincteric fatigue was experimentally prepared by electrically stimulating the pudendal nerves at 15 V, 20 Hz for 30 to 40 minutes. In fatigued sphincters, CB (n = 17) and TB (n = 7) increased the contracting pressure (pressure difference between stimulation-generated peak level and baseline level of IUP). The inotropic effect of beta 2-stimulant (TB) on the fatigued urethral sphincter was abolished by a beta-blocker, propranolol. From the present study it was concluded that beta 2-stimulants have little effect on the total contractility of the nonfatigued urethral sphincter because it is composed of smooth and striated muscles (fast- and slow-contracting muscles). However, beta 2-stimulants enhanced the contractility of fatigued urethral sphincter. These results suggest that beta 2-stimulants act on fast-contracting fibers in the urethral sphincter because the inotropic effect of sympathomimetic amine is much greater on fatigued, fast-contracting fibers than on nonfatigued ones and its depressive effect on slow-contracting fibers is not potentiated after fatigue.

The nature of detrusor bladder neck dyssynergia in non-neurogenic bladder dysfunction.

There have been two major opinions on the pathology or nature of the bladder neck contracture. One is an organic fibrosis, and the other is an accentuated sympathetic nervous function, or detrusor bladder neck dyssynergia. The existence of active detrusor bladder neck dyssynergia in neurogenic bladder was reported in a urodynamical manner using microtip transducer catheters. However, it has not been confirmed whether or not detrusor bladder neck dyssynergia is responsible for bladder neck contracture in patient without neurogenic bladder. The present study was designed to determine by means of video urodynamic study whether or not bladder neck contracture would be of the same nature as detrusor bladder neck dyssynergia in non-neurogenic bladder subjects. The study included 32 male subjects of 16-84 years old (average 52.3): 17 bladder neck contracture subjects including 7 subjects associated with minimum complications (4 with trapped benign prostatic hyperplasia and 3 with incomplete neurological lesion) and 15 non-bladder neck contracture subjects (10 healthy volunteers, 2 chronic prostatitis, 3 prostatodynia). A 5-microtip transducer catheter was used to measure the pressure in the bladder and at the bladder neck, the external urethral sphincter and the bulbous urethra during voiding. Proper localization of the transducers was done with an image intensifier. Bladder outlet obstruction localized at the bladder neck (diameters smaller than 0.75 cm) on voiding cystourethrogram was defined as bladder neck contracture. Detrusor bladder neck dyssynergia was defined where pressures were higher at the level of bladder neck than in the bladder during detrusor contraction. An alpha-blocker, terazosin hydrochloride (0.5 mg, b.i.d., two weeks), was orally administered to subjects judged to have detrusor bladder neck dyssynergia by the above methods for the purpose of confirming whether detrusor bladder neck dyssynergia was really due to accentuated sympathetic nervous function. Detrusor bladder neck dyssynergia was found in seven cases with bladder neck contracture: 6 cases with bladder neck contracture with minimum complications and only 1 case with bladder neck contracture without complications (p < 0.01). Detrusor bladder neck dyssynergia was found at the beginning and ending of micturition, but not at maximum flow. In six cases with detrusor bladder neck dyssynergia, the condition disappeared after terazosin. In conclusion, detrusor bladder neck dyssynergia was not thought to be a major factor of voiding dysfunction in bladder neck contracture in non-neurogenic bladder. In the presence of sympathetic hyperactivity or in cases with increased number of alphareceptors, detrusor bladder neck dyssynergia occurs, being predominantly noted in trapped benign prostatic hyperplasia and neurological disorder patients.

Micturitional disturbance in myotonic dystrophy

Micturitional disturbance has attracted little attention in myotonic dystrophy, but detailed micturitional histories revealed that two out of six patients (33%) had micturitional symptoms. One had difficulty urinating and the other had urinary frequency, urgency and stress incontinence. Urodynamic studies were performed in all patients and the results were as follows: Two had low maximum urethral closure pressure, two had large and three had small bladder capacities, one had detrusor hyperreflexia and one had atonic cystometrogram. Urethral sphincter electromyography revealed a decreased bulbocavernosus reflex in one, and an absent anal reflex in two. Motor unit analysis of external sphincter was performed with one patient and showed polyphasic potentials. Dystrophic changes of the lower urinary tract muscles, as well as supranuclear type of pelvic nerve dysfunction, could cause micturitional disturbance in patients with myotonic dystrophy.

micturitional Disturbance in Radiation Myelopathy

Detailed micturitional histories and urodynamic studies were performed in five patients with radiation myelopathy. All patients had micturitional symptoms that were irritative in five and obstructive in four, and four had urinary incontinence. Urodynamic studies showed that three patients had residual urine of 158 ml on average. Cystometry showed that four patients had detrusor hyperreflexia and one had low compliance cystometrogram. External sphincter electromyography showed that four patients had detrusor-sphincter dyssynergia. These results indicated that micturitional disturbance seemed to be common and severe in storage as well as evacuation function. The main responsible sites of lesions seemed to be supranuclear parasympathetic and somatic nervous systems regulating the lower urinary tract. Two of three patients who underwent combination of steroid pulse therapy and hyperbaric oxygen therapy experienced improvement of micturitional disturbance and other neurological deficits.

Change of External Urethral Sphincter Function in Prostatic Patients

External urethral function was urodynamically examined in 13 patients with benign prostatic hypertrophy (BPH) associated with chronic urinary retention and in 5 volunteers. Prevoiding drop in external urethral sphincter pressure was noted in all the volunteers, whereas it was not found in 6 of the 13 cases of BPH. Bladder neck opening pressure was higher in these 6 cases (p less than 0.05). After administration of phentolamine, prevoiding drop was noted in 5 of these 6 cases, and bladder neck opening pressure decreased so much that there was no significant intergroup difference. The above results mean that the increase in alpha-adrenergic receptors makes the prostate, which has been already hypertrophied, less elastic, inhibiting external urinary sphincter function.

Improvement of urethral resistance after the administration of an alpha-adrenoceptor blocking agent, urapidil, for neuropathic voiding dysfunction

We assessed the effect of a new alpha-blocking agent, Urapidil, on neuropathic voiding dysfunction, by urodynamic studies. The residual urine volume and rate significantly decreased, whereas the average and the maximum flow rate did not increase significantly. The pressure at maximum flow and minimum urethral resistance decreased significantly. These results suggest that improvement of the voiding dysfunction in some cases could be due to the decreased micturition pressure without increasing the flow rate. The urethral resistance calculated from the pressure/flow data seemed to be a valuable index in evaluating the effects of the drug on neuropathic voiding dysfunction.