T. Yamanishi

Colonic transit time, sphincter EMG, and rectoanal videomanometry in multiple system atrophy.

Both constipation and fecal incontinence are prominent lower gastrointestinal tract (LGIT) dysfunctions that occur frequently in multiple system atrophy (MSA). We investigated the mechanism of constipation and fecal incontinence in MSA. Colonic transit time (CTT), sphincter electromyography (EMG), and rectoanal videomanometry were performed in 15 patients with MSA (10 men, 5 women; mean age, 63.5 years; mean duration of disease, 3 years; decreased bowel frequency [< 3 times a week] in 9; difficulty in expulsion in 11; fecal incontinence in 3) and 10 age‐matched healthy control subjects (7 men and 3 women; mean age, 62 years; decreased bowel frequency in 2; mild difficulty in expulsion in 2; fecal incontinence in none). Compared to the control subjects, MSA patients had significantly prolonged CTT in the rectosigmoid segment and total colon. Sphincter EMG showed neurogenic motor unit potentials in none of control subjects but in 93% of MSA patients. At the resting state, MSA patients showed a lower anal squeeze pressure (external sphincter weakness) and a smaller increase in abdominal pressure on coughing. During rectal filling, MSA patients showed smaller amplitude in phasic rectal contraction, which was accompanied by an increase in anal pressure that normally decreased, together with leaking in 3 patients. During defecation, most MSA patients could not defecate completely and had larger postdefecation residuals. MSA patients had weak abdominal strain, smaller rectal contraction on defecation, and larger anal contraction on defecation (paradoxical sphincter contraction on defecation), although these differences were not statistically significant. These findings in MSA patients were similar to those in Parkinsons disease patients in our previous study, except for the sphincter denervation and weakness in MSA. Constipation in MSA most probably results from slow colonic transit, decreased phasic rectal contraction, and weak abdominal strain, and fecal incontinence results from weak anal sphincter due to denervation. The responsible sites for these dysfunctions seem to be both central and peripheral nervous systems that regulate the LGIT.

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.

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.

Micturitional disturbance in pure autonomic failure

Article abstract We obtained micturitional histories and performed urodynamic studies in six patients with pure autonomic failure. All patients had urinary symptoms. Urodynamic studies showed postmicturition residuals in two, small bladder capacities in two, detrusor hyperreflexia in four, low bladder compliance in two, detrusor-external sphincter dyssynergia in one, neurogenic sphincter electromyography in three, and denervation supersensitivity of the bladder in two. Micturitional disturbance is a common feature in pure autonomic failure because of peripheral and central types of abnormalities.

Psychogenic urinary dysfunction: a uro-neurological assessment.

AIMSnThe diagnosis of psychogenic urinary dysfunction (PUD) is one of exclusion, particularly from urologic and neurologic causes, and is usually accompanied by more obvious psychologic/ psychiatric features. We here describe patients with PUD who were diagnosed in our uro- neurological laboratory.nnnMATERIALS AND METHODSnWe reviewed the digitized records of 2,300 urodynamic cases treated in the past 6 years to identify patients who fulfilled the diagnostic criteria of PUD. All 2,300 patients had completed a urinary questionnaire and undergone both electromyography (EMG)-cystometry and a detailed neurological examination. In addition, pressure-flow analysis, neurophysiology tests including sphincter EMG analysis, and MRI of the brain and spinal cord were performed as applicable.nnnRESULTSnPUD was seen in 16 cases (0.7%): 6 men, 10 women, mean age 37 years. Lower urinary tract symptoms (LUTS) included overactive bladder (OAB) alone in 5, difficult urination alone in one, and both in 10. LUTS commonly occurred in particular situations, for example, OAB only while riding the train. Some patients showed extremely infrequent toileting. The urodynamic findings were normal except for increased bladder sensation (50%) for OAB and acontractile detrusor (31%) for difficulty. The final diagnosis was conversion reaction in six followed by anxiety in four.nnnCONCLUSIONSnPUD patients experienced the situational occurrence of OAB and/or difficult urination and, in some patients, extremely infrequent toileting. The main urodynamic abnormalities were increased bladder sensation and acontractile detrusor. However, even in cases suggestive of PUD, a non-PUD pathology behind the symptoms should be explored.

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.

Micturitional disturbance in patients with chronic inflammatory demyelinating polyneuropathy

Eight of 32 patients (25%) with chronic inflammatory demyelinating polyneuropathy (CIDP) had micturitional disturbance, which consisted of voiding difficulty (n = 4), urgency (n = 4), or urgency incontinence (n = 1). Urodynamic studies on four symptomatic patients showed disturbed bladder sensation in two, bladder areflexia in one, and neurogenic changes of the external sphincter in one, indicative of peripheral parasympathetic and somatic nerve dysfunctions. Cystometry also showed detrusor over-activity in two patients but no evidence of CNS involvement, evidence that bladder overactivity occurs by probable pelvic nerve irritation.

Urodynamic and cardiovascular measurements in patients with micturition syncope

We describe the findings of urodynamic studies, together with blood pressure and heart rate monitoring, in five patients with micturition syncope. All patients had almost normal storage and evacuation function and no evidence of prostate hypertrophy. Conventional head-up tilt testing with an empty urinary bladder caused no change in arterial blood pressure, but a moderate increase in heart rate. Urinary bladder filling caused minimal increases of the arterial pressure and heart rate. The sitting posture with a distended bladder caused mild orthostatic hypotension. Urinary bladder evacuation caused a fall in arterial pressure with a decrease in heart rate. These responses were similar to those described in vasovagal syncope. The central mechanism for the initiation of urinary evacuation, or sensory input from the lower urinary tract, may trigger micturition syncope.

Relationship Between Bladder Neck Diameter and Hydraulic Energy at Maximum Flow

A pressure-flow study was performed with a 5-micro-tip transducer catheter in 6 normal male volunteers (bladder neck diameters 0.80 cm. or larger) and 13 male subjects suspected of having bladder neck contracture. Intraurethral pressure was measured at various sites in the urethra at maximum flow to calculate hydraulic energy at these sites using the Bernoulli equation. When the subjects were divided into 2 groups (1 group with a bladder neck diameter of 0.73 cm. or larger and 1 with a bladder neck diameter of 0.60 cm. or smaller), the relative value of energy (ratios to the initial energy generated in the bladder) at the external urethral sphincter was significantly (p < 0.01) greater in the former than in the latter group. Therefore, the flow rate controlling zone lies at the external urethral sphincter in the former group and at the bladder neck in the latter group.

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.