Naoto Murayama

BIOFEEDBACK TRAINING FOR DETRUSOR OVERACTIVITY IN CHILDREN

PURPOSE We evaluated biofeedback training for incontinence due to detrusor overactivity in children. MATERIALS AND METHODS Included in our study were 22 boys and 17 girls with a mean age of 11.2 years. We noted nighttime incontinence in 3 patients, nighttime incontinence and daytime urinary symptoms in 26, and daytime incontinence in 10. All patients had detrusor overactivity and incontinence refractory to conventional treatment, including bladder training, tricyclic antidepressants, anticholinergics, desmopressin and/or conditioning therapy. Urodynamic study was performed using an 8Fr double lumen transurethral catheter for cystometry, a double balloon transrectal catheter for rectal pressure and external anal sphincter pressure measurement, and surface electrodes for sphincter electromyography. During biofeedback training patients were instructed to contract the anal sphincter without raising abdominal pressure to inhibit overactive bladder contractions. Biofeedback training was repeated monthly until cystometry revealed a stable bladder or lower urinary tract symptoms improved considerably. RESULTS Four patients were lost to followup. Of the remaining 35 children urinary symptoms were cured in 23 and improved in 4. Urodynamic studies after 6 months of biofeedback training in 33 cases showed that bladder overactivity disappeared in 10 and improved in 18. Bladder capacity at the initial desire to void and maximum cystometric capacity increased significantly (p = 0.0115 and <0.0001, respectively). Detrusor-sphincter dyssynergia in 2 patients before biofeedback training resolved in each after therapy. CONCLUSIONS Biofeedback training for detrusor overactivity is effective even in pediatric cases refractory to conventional treatment.

Detrusor Overactivity and Penile Erection in Patients with Lower Lumbar Spine Lesions

Objectives: To investigate urodynamically detrusor overactivity and evaluate surgical outcome in patients with lower lumbar spine lesions. Methods: Eighty patients with spine lesions below the third lumbar spine including 31 patients with intervertebral disc prolapse (IDP) (mean age: 38.2 years) and 49 patients with spinal canal stenosis (SCS) (mean age: 56.7 years) were studied. Urinary symptoms and urodynamic data were recorded before and after orthopedic surgery. Results: Detrusor overactivity was noted in 17 patients: 3 IDP patients (10%) and 14 SCS patients (29%). Of these 17 patients (9 males and 8 females), 14 (82%) had voiding symptoms and 15 (88%) had storage symptoms. One patient was asymptomatic. Intermittent claudication was noted in 14 patients: 8 had urgency, 11 urge incontinence and 4 male patients showed erection on walking. Of 10 patients followed up after surgery, detrusor overactivity disappeared in 5 patients, improved in 1 patient and remained unchanged in 4 patients. Conclusions: Detrusor overactivity was found in lower lumbar spine lesions. This phenomenon seemed to be caused by the irritation of sacral roots, especially on walking.

Micturitional Disturbance in Cervical Spondylotic Myelopathy

Neurourological studies were performed on 37 patients with cervical spondylotic myelopathy. Micturitional history revealed that 30 patients (81%) had voiding symptoms: obstructive in 14, irritative in 5, and both symptoms in 11. Urodynamic studies revealed that 9 of 20 had abnormal uroflowmetrogram, 17 of 37 had residual urine, 14 of 37 had detrusor hyperreflexia, and 6 of 37 had detrusor-sphincter dyssynergia. There were no statistical differences in lower extremity neurological signs in patients with or without residual urine.

Urethral obstruction in patients with nighttime wetting: Urodynamic evaluation and outcome of surgical incision

The aim of this study was to investigate urodynamic findings and the outcome of surgical incision in patients with nighttime wetting due to urethral obstruction. A total of 239 patients with nighttime wetting (157 males and 82 females; mean age, 8.7; range, 4–18 years) was studied. One hundred and ten patients had monosymptomatic enuresis alone and 129 both nighttime wetting and daytime symptoms, that is, the majority was not simple bedwetters, but had signs of bladder overactivity. All patients were first treated with bladder training and fluid intake after dinner was restricted. The non‐responders were then treated with tricyclic antidepressants, anticholinergics, or intra‐nasal desmopressin and conditioning therapy. Ninety‐seven patients who did not respond to these conventional treatments were investigated by voiding cystourethrography, bougie à boule, and urodynamic study. Urethral obstruction was noted in 34 patients (14.2%); posterior urethral valves in three males, ring stricture of the bulbar urethra in 26 males and distal urethral stenosis in five females. Detrusor instability was noted in 30 (94%) of 32 patients. Three patients had <15 mL/s of maximum flow rate and none had post‐void residual urine. Pressure at maximum flow (PQmax) was 106.5 ± 26.3 cm H2O in pressure/flow study. After surgery, nighttime wetting was cured in 25 patients (73.5%), improved in four (11.8%). Detrusor instability disappeared in six of 16 patients studied (37.5%) and improved in 8 (50%), and PQmax decreased significantly after operation (P = 0.0034). In conclusion, most of the patients with urethral obstruction have detrusor instability and high pressure voiding, and these conditions improved after operation. Neurourol. Urodynam. 19:241–248, 2000.

Lower Urinary Tract Dysfunction in the Anterior Spinal Artery Syndrome

Lower urinary tract function was studied in 10 patients with the anterior spinal artery syndrome. In the acute stage all patients had complete urinary retention. Cystometry in 3 patients showed detrusor areflexia. At a neurologically stable stage 9 patients could void and 1 had urinary retention during the preceding 7 years. Cystometric bladder capacities at first and maximum desire to void were decreased in 8 patients and normal in 2. Detrusor hyperreflexia was noted in 8 patients, a normal bladder in 1 and detrusor areflexia in 1. External urethral sphincter electromyography revealed detrusor-sphincter dyssynergia in 4 patients and normal findings in 6. We conclude that the vesicomotor dysfunction in this syndrome is similar to that of traumatic spinal cord injury except that bladder sensation is preserved. The latter finding indicates that at least some of the bladder sensation travels via the posterior columns of the spinal cord.

Surgical repair of anterior hypospadias with fish-mouth meatus and intact prepuce based on anatomical characteristics.

Purpose: A variant form of anterior hypospadias, called a megameatus and intact prepuce (MIP), is thought to be less amenable to conventional distal hypospadias repair. The feasibility of using the standard technique with a parameatal-based foreskin flap is described herein. Materials and Methods: Nine children with the MIP variant underwent repair. A foreskin flap for urethroplasty was harvested from either the ventral (Mathiew) or unilateral site. The glans was split along with the cleft glanular groove to create the glans wings. The flap was laid on the urethral plate to form a neourethra, and glanulomeatoplasty was completed by approximation of the glans wings. Sleeve reapproximation of the penile foreskin was performed for uncircumcised skin closure. Results: The functional and cosmetic results of the procedure were excellent in 8 cases including 1 with temporary postoperative edema of redundant foreskin. The last case underwent excision of the ventral excess foreskin for cosmetic reasons. Conclusions: Although the etiology of the MIP variant remains obscure, the urethral plate distal to the meatus is uniformly pliable and healthy in this variant. Furthermore, the ventral portion just proximal to the meatus is well developed and not atretic so that the parameatal ventral foreskin is safely harvested for onlay urethroplasty.

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.

Disturbances of micturition in patients with a spinal arteriovenous malformation

Neuro-urological studies were performed on 9 patients with a spinal arteriovenous malformation (S-AVM). The micturitional history revealed that all 9 patients had voiding symptoms, obstructive in 9 and irritative in 3 patients. All patients still had obstructive symptoms after treatment of S-AVM. Six of the 9 patients had a large volume of residual urine before treatment; 5 showed urinary retention. Four of the 5 patients (80%) for whom urodynamic studies were performed before treatment had micturitional dysfunction; 2 patients had detrusor hyperreflexia, 1 with detrusor external urethral sphincter dyssynergia (DSD) and 1 with a normal sphincter, 1 patient had an autonomous bladder with DSD and 1 patient had an atonic bladder with DSD. Only 1 patient had a normal bladder and sphincter. Findings of the urodynamic studies after treatment in 9 patients showed detrusor hyperreflexia in 3 patients (2 with DSD and 1 with normal sphincter), autonomous bladder in 1 patient with DSD, atonic bladder in 4 patients (2 with DSD, 1 with incompetent sphincter and 1 with normal sphincter) and normal bladder with normal sphincter in 1 patient. Lower urinary function after treatment of S-AVM was improved in 2 patients, unchanged in 4 patients and worsened in 3 patients.The above results showed 80% of S-AVM had a severe neuropathic bladder manifested mainly by disturbance of micturition. Treatment of S-AVM does not necessarily improve the lower urinary tract function.