Yusuke Awa

Incomplete emptying and urinary retention in multiple-system atrophy: When does it occur and how do we manage it?

Neurogenic urinary retention can be a major cause of morbidity in multiple‐system atrophy (MSA). However, the timing of its appearance has not been entirely clear, and neither have the medical and surgical modalities for managing patients. We present the data obtained from our uroneurological assessment and therapeutic interventions at various stages of MSA. We recruited 245 patients with probable MSA. We measured postvoid residuals (PVR) and performed EMG cystometry in all patients. The grand average volume of PVR was 140 mL (range, 0–760) in our patients. The average PVR volume was 71 mL in the first year, increasing to 129 mL in the second year and 170 mL by the fifth year. The percentages of patients with complete urinary retention, acontractile detrusor, and detrusor–sphincter dyssynergia (DSD) also increased. The increase in PVR resulted in a decrease in functional bladder capacity, together with an increase in detrusor overactivity and neurogenic sphincter EMG. Clean intermittent self‐catheterization (CISC) was introduced in most patients. Bladder‐oriented therapy (cholinergic agents) had a limited value, whereas urethra‐oriented therapy benefited patients with DSD (surgery) for up to 2 years, but syncope occurred in a subset of patients (α‐blockers). MSA patients present with large PVR by the second year of illness, and that large PVR secondarily causes urinary frequency. CISC is the recommended treatment for most patients. Urethra‐oriented medication and surgery benefit patients who would have difficulty performing CISC, although careful consideration of the short‐term efficacy and potential adverse effects of these alternatives is mandatory.

Urinary dysfunction in early and untreated Parkinson's disease

Background Urinary dysfunction is common in Parkinsons disease (PD); however, little is known about urinary dysfunction in early and untreated PD patients. Methods Fifty consecutive untreated PD patients (mean age, 66.7; mean disease duration, 23.6 months; and mean Hoehn & Yahr scale, 1.9) were recruited; those with other conditions that might have influenced urinary function were excluded. Patients were evaluated using a urinary questionnaire and urodynamic studies. Results Sixty-four per cent complained of urinary symptoms (storage, 64.0%; voiding, 28.0%). Urodynamic studies showed abnormal findings in the storage phase in 84%, with detrusor overactivity (DO) and increased bladder sensation without DO in 58.0% and 12.0% of patients, respectively. In the voiding phase, detrusor underactivity, impaired urethral relaxation such as detrusor sphincter dyssynergia, and bladder outlet obstruction were present in 50.0%, 8.0% and 16% of patients, respectively. In patients with both storage and voiding phase abnormalities, DO+detrusor underactivity was the most common finding. Few patients experienced urge incontinence and/or quality-of-life impairment owing to urinary dysfunction; none had low-compliance bladder or abnormal anal-sphincter motor unit potential. These urinary symptoms and urodynamic findings were not correlated with gender, disease severity or motor symptom type. Conclusion Urinary dysfunction, manifested primarily as storage disorders with subclinical voiding disorders and normal anal-sphincter electromyography, occurs in early and untreated PD patients. In cases with severe voiding disorder and/or abnormal anal-sphincter electromyography, other diagnoses should be considered.

When is Onuf's nucleus involved in multiple system atrophy? A sphincter electromyography study

Background: External anal sphincter (EAS) electromyography (EMG) abnormalities can distinguish multiple system atrophy (MSA) from Parkinson’s disease in the first five years after disease onset. However, the prevalence of the abnormalities in the early stages of MSA is unknown. Objectives: To present EAS-EMG data in the various stages of MSA. Methods: 84 patients with “probable” MSA were recruited (42 men, 42 women; mean age 62 years (range 47 to 78); mean disease duration 3.2 years (0.5 to 8.0; <1 year in 25%); 50 cerebellar form (MSA-C), 34 parkinsonian form (MSA-P)). EAS motor unit potential (MUP) analysis and EMG cystometry were carried out in all patients. Results: The overall prevalence of neurogenic change of the EAS MUP was 62%—52% in the first year after disease onset, increasing to 83% by the fifth year (p<0.05); it also increased with severity of gait disturbance (p<0.05), storage and voiding disorders, and detrusor sphincter dyssynergy (NS). The neurogenic change was not correlated with sex, age, MSA-P/C, postural hypotension, constipation, erectile dysfunction in men, underactive or acontractile detrusor, or detrusor overactivity. In 17 incontinent patients without detrusor overactivity or low compliance, urinary incontinence was more severe in those with neurogenic change than in those without (p<0.05). Conclusions: Involvement of Onuf’s nucleus in MSA is time dependent. Before the fifth year of illness, the prevalence of neurogenic change does not seem to be high, so a negative result cannot exclude the diagnosis of MSA.

Low dose tamsulosin for stone expulsion after extracorporeal shock wave lithotripsy: Efficacy in Japanese male patients with ureteral stone

Objective:  We evaluated the efficacy of low dose tamsulosin after extracorporeal shock wave lithotripsy (ESWL) in Japanese male patients with ureteral stone.

HOW TO MANAGE OVERACTIVE BLADDER IN ELDERLY INDIVIDUALS WITH DEMENTIA? A COMBINED USE OF DONEPEZIL, A CENTRAL ACETYLCHOLINESTERASE INHIBITOR, AND PROPIVERINE, A PERIPHERAL MUSCARINE RECEPTOR ANTAGONIST

routine CSF analysis, and electroencephalography. Our case is highly unusual, with early neuroimaging abnormalities and near-normal routine CSF findings. PCR confirmed HSE the same day. This case emphasizes the importance of early neuroimaging in elderly patients suspected of having HSE without CSF abnormalities. PCR detection of HSV DNA in CSF is presently considered to be the reference standard but may be negative during the first 24 to 48 hours after onset of symptoms. Also, PCR sensitivity can diminish 5 to 7 days after commencing antiviral treatment. EEGs show temporal lobe involvement as well as characteristic PLEDs and are fairly sensitive, particularly during the first 48 hours, although lacking specificity. Several publications have recently reported on the diagnostic value of diffusion-weighted MRI, suggesting that it is more sensitive than conventional T2weighted sequences in the early detection of HSE, although conclusive studies have not yet been performed. CT scans typically reveal hypodensities in the temporal lobes and frontal lobes (unior bilaterally), rarely with hemorrhagic components, and show gadolinium enhancement only during later stages of the disease. T2-weighted and MRI imaging studies, as well as fluid attenuated inversion recovery and diffusion-weighted sequences, commonly show more-extensive abnormalities corresponding to tissue edema, often including the inferior frontal and medial temporal lobes, and insular cortex and often sparing the basal ganglia. The neuroradiological findings in this patient are typical for HSE, although they appeared unusually early. Diagnostic tools are evolving but presently do not offer high enough sensitivity to exclude the presence of HSV in the early stages of the disease. Our case report suggests that conventional MRI should be performed early in the absence of other diagnostic clues. The efficacy of acyclovir 10 mg/kg given every 8 hours for 21 days has been proven in two randomized clinical trials. The effect of dexamethasone as an adjuvant treatment on survival and neurological sequelae of HSE in adults is being studied in the German trial of Acyclovir and Corticosteroids in Herpes Simplex Encephalitis, which is planned to conclude in 2011. In our patient, early acyclovir treatmentFbefore a pleocytosis appearedFdid not have a significant effect on outcome.

Meningitis-retention syndrome : An unrecognized clinical condition

AbstractBackgroundA combination of acute urinary retention and aseptic meningitis has not been well known. This combination can be referred to as meningitis–retention syndrome (MRS), when accompanied by no other abnormalities.ObjectiveTo describe the results of a uro–neurological assessment in our patients with MRS.MethodsIn three patients (two men, one woman; age, 34–68 years), we performed urodynamic studies and relevant imaging and neurophysiological tests, in addition to cerebrospinal fluid (CSF) examination.ResultsAll three patients developed acute urinary retention along with headache, fever and stiff neck.None had obvious neurological abnormalities, other than a slightly brisk reflex in the lower extremities. One had previously experienced generalized erythematous eruptions, but none had pain, hypalgesia or skin eruptions in the sacral dermatomes suggestive of Elsberg syndrome (infectious sacral polyradiculitis; mostly genital herpes). Brain/spinal/lumbar plexus MRI scans and nerve conduction studies were normal. CSF examination showed mild mononuclear pleocytosis, increased protein content, and normal to mildly decreased glucose content in all patients; increased myelin basic protein suggestive of central nervous system demyelination in one; and increased viral titers in none.Urodynamic study revealed, during the voiding phase, an underactive detrusor in all patients and an unrelaxing sphincter in one. These clinical manifestations were ameliorated within 3 weeks.ConclusionsWe reported three cases of MRS, a peculiar syndrome that could be regarded as a mild variant of acute disseminated encephalomyelitis (ADEM). Urinary retention might reflect acute shock phase of this disorder. Although MRS has a benign and selfremitting course, management of the acute urinary retention is necessary.

Prevalence and mechanism of bladder dysfunction in Guillain-Barré Syndrome.

To examine the prevalence and mechanism of urinary dysfunction in GBS.

Clinical impact of tamsulosin on generic and symptom‐specific quality of life for benign prostatic hyperplasia patients: Using international prostate symptom score and Rand Medical Outcomes Study 36‐item Health Survey

Aim: To examine the efficiency of α1‐blocker treatment on disease‐specific and generic quality of life (QOL) in men with clinically diagnosed benign prostatic hyperplasia (BPH), the improvement of QOL scores with International prostate symptom score (I‐PSS) and Rand Medical Outcomes Study 36‐item Health Survey (SF‐36) was prospectively analyzed.

Effects of Milnacipran and Paroxetine on Overactive Bladder due to Neurologic Diseases: A Urodynamic Assessment

Aims: To determine the effects of milnacipran hydrochloride, a serotonin-norepinephrine reuptake inhibitor (SNRI), or paroxetine hydrochloride, a selective serotonin reuptake inhibitor, on overactive bladder (OAB) in neurologic diseases, given by objective measures of urodynamic studies. Methods: This is a prospective open trial, and we enrolled 24 patients (16 men, 8 women; mean age, 63.9 years) with OAB in a neurology clinic. They were randomly allocated into two groups: the milnacipran group (11 patients), and paroxetine group (13 patients). We started with 100 mg/day of milnacipran or 40 mg/day of paroxetine. Before and 3 months after the treatment, we performed a urinary questionnaire and urodynamic studies. Results: Milnacipran reduced daytime urinary frequency (average, from 9.4 to 7.1 times, p < 0.001), improved the quality of life index (p = 0.023), and increased bladder capacity (average, from 289 to 377 ml, p = 0.009) as shown in urodynamic studies. No such changes were noted in the other categories of the lower urinary tract symptoms questionnaire or urodynamic studies, or in the paroxetine group. One male patient complained of mild voiding difficulty. Other adverse effects were not seen during the observation period. Conclusion: Milnacipran, an SNRI, increased bladder capacity as shown in urodynamic studies, and thereby ameliorated OAB in patients with neurologic diseases without serious adverse effects.

Real-time measurement of oxyhemoglobin concentration changes in the frontal micturition area: an fNIRS study

To explore brain activity in the frontal micturition area during natural bladder behavior.