December 4, 2016

Re: Detrusor Underactivity and the Underactive Bladder: Symptoms, Function, Cause—What do we Mean? ICI-RS Think Tank 2014

Re: Detrusor Underactivity and the Underactive Bladder: Symptoms, Function, Cause—What do we Mean? ICI-RS Think Tank 2014

  • Alan J. Wein, MD, PhD (hon)

P. P. Smith, L. A. Birder, P. Abrams, A. J. Wein and C. R. Chapple
Department of Surgery, Center on Aging, University of Connecticut Health Center, Farmington, Connecticut, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh and Department of Urology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, and Bristol Urologic Institute, Southmead Hospital, Bristol and Department of Urology, Royal Hallamshire Hospital, Sheffield Hallam University, Sheffield, United Kingdom
Neurourol Urodyn 2016;35:312–317.doi: 10.1002/nau.22807

Editorial Comment

It seems like “underactive bladder” (UAB) and “detrusor underactivity” (DU) are 2 buzzwords that will constitute the focus of a subject that will be the point of discussion by those interested in lower urinary tract dysfunction for at least the next few years. The relationship of symptoms, function and cause constitutes the focus of this report resulting from a 2014 International Consultation on Incontinence-Research Society Think Tank titled, “Does detrusor underactivity exist, and if so is it neurogenic, myogenic, or both?” Although publication has obviously been delayed, the summary is still quite contemporary regarding the problems and pitfalls inherent in the definitions, diagnosis and therapy of the conditions encompassed by these 2 terms. Equating UAB with DU and impaired contractility is attempting simplification, which unfortunately leads only to confusion. The terms are not interchangeable.
Although proposals for improving terminology have emerged since this think tank, the authors provide a very good introduction to the conceptual overlap of symptoms (underactive bladder), function (detrusor underactivity) and etiology, and how the overlap of these circles may vary across subpopulations and within individuals as a consequence of disease and aging. Detrusor underactivity is a description of objective inadequacy of voiding, and, therefore, a measure of function and not etiology. A formal accepted definition of DU is lacking, and any such definition is relative to normal voiding characteristics and limited by an incomplete phenotyping of voiding in specific populations (ie based on age and gender).
The authors describe “impaired contractility” as indicating an inherent muscular failure to generate an adequate output in the presence of sufficient metabolic substrate and normal levels of neurological stimulation. They propose that “detrusor underactivity” should be preserved for urodynamic findings as described in the original International Continence Society definition, the problem being, of course, that no one knows what constitutes a contraction of reduced strength and/or duration, a normal time span or complete bladder emptying. The authors propose that “according to an integrative hypothesis, detrusor underactivity is a relative functional threshold deficiency resulting from failure of biological adaptation to multiple systemic failures.” They propose that “underactive bladder” should be reserved for the symptom complex of prolonged urination, with or without a sensation of incomplete bladder emptying, usually with hesitancy in a slow stream. This term should not be taken to imply a specific pathology or etiology and may or may not constitute an accurate perception of detrusor underactivity. However, that is to formally be finally defined. As the authors suggested at that think tank, focus groups are now trying to define what amounts to a symptom complex of underactive bladder and how this relates to clinically observed dysfunction (detrusor underactivity). However, that is to be defined in age specific and gender specific populations.
Although this summary is not the “last word” in contemporary discussions of the concepts of UAB, DU or impaired contractility, it is good background information for anyone interested in the subject with reference to the difficulties that arise when trying to define these entities. The “elephant in the room,” ie successful therapy or the lack of successful therapy, is left to subsequent discussions.

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Underactive bladder syndrome

Underactive bladder syndrome

Deborah Rigby 
Continence service manager. 
Bristol South and West PCT, Knowle West, Bristol
Nursing Standard. 19, 35, 57-68. http://dx.doi.org/10.7748/ns.19.35.57.s54

Double blind peer review

Underactive bladder syndrome causes difficulty in voiding, resulting in incomplete bladder emptying. This article describes common causes of the condition, patient assessment and the available management options.

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Management of bladder dysfunction in patients with multiple sclerosis

Management of bladder dysfunction in patients with multiple sclerosis

David Williams Urology specialist nurse. SureCalm Healthcare, Manchester

Nursing Standard. 26, 25, 39-46. http://dx.doi.org/10.7748/ns2012.02.26.25.39.c8951

Double blind peer review

Multiple sclerosis is a chronic disease of the central nervous system that often has a disabling effect, resulting in reduced quality of life for patients. Bladder dysfunction is a common and distressing symptom. Nurses can have a key role in the management of this symptom by promoting an integrated approach to care, thereby improving bladder control and reducing patient anxiety. This article explores the core elements of a specialist continence assessment in this patient group, and provides a critical overview of treatments used for managing bladder problems.



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September 12, 2016

The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review.

The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review.
Arab J Urol. 2016 Sep;14(3):223-7
Authors: Ahmed A, Farhan B, Vernez S, Ghoniem GM
Abstract
OBJECTIVE: To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research.
METHODS: We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: 'detrusor underactivity', 'underactive bladder', 'post voiding residual', 'post micturition residual', 'acontractile bladder', 'detrusor failure', and 'detrusor areflexia'.
RESULT: DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function.
CONCLUSION: Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.
PMID: 27547465 [PubMed]
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August 23, 2016

Urothelial ATP signaling: what is its role in bladder sensation?


Urothelial ATP signaling: what is its role in bladder sensation?

Authors: Kentaro Takezawa, Makoto Kondo, Norio Nonomura, Shoichi Shimada

Abstract

AIM

Bladder functional disorders are common health problems; however, their pathologies are poorly understood. Adenosine triphosphate (ATP) released from the urothelium has been suggested to have an essential role in the micturition reflex, and its involvement in bladder functional disorders has been intensively investigated. Here, we review the latest advances in research on urothelial ATP signaling.

METHODS

We reviewed research articles on the role of the urothelium and urothelial ATP release in bladder function.

RESULTS

Mice lacking purinergic receptors have been reported to exhibit marked bladder hyporeflexia. Based on this observation, it was commonly believed, according to the widely held ATP urothelial signaling theory, that stretch-induced urothelial ATP release mediates the sensation of bladder filling via purinergic receptors. However, recent studies employing novel experimental methods and approaches have demonstrated that there are no significant differences in bladder function between wild-type and purinergic receptor knockout mice under physiological conditions. Nonetheless, under pathological conditions, inhibition of purinergic receptors has been shown to improve bladder hyperactivity. Moreover, enhanced urothelial ATP release has been reported in patients with bladder functional disorders.

CONCLUSIONS

Recently, conflicting evidence has led us to question the role of urothelial ATP signaling in normal micturition reflex. In contrast, under pathological conditions, it seems likely that enhanced urothelial ATP signaling mediates bladder hyperactivity. These recent findings suggest that the urothelial ATP signaling pathway is a potential therapeutic target for bladder functional disorders.
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August 12, 2016

A pilot study of cardiac electrophysiology catheters to map and pace bladder electrical activity.

A pilot study of cardiac electrophysiology catheters to map and pace bladder electrical activity.
Neurourol Urodyn. 2016 Aug 5;
Authors: Kelley RS, Vardy MD, Simons G, Chen H, Ascher-Walsh C, Brodman M
Abstract
AIMS: This is a pilot study to evaluate the feasibility of using diagnostic cardiac electrophysiology catheters for recording intrinsic urinary bladder electrical activity and for electrical pacing capture of bladder tissue.
METHODS: During cystoscopy, a curved quadripolar catheter was introduced and contact was made with the right and left halves of the dome and trigone in adult female patients undergoing cystoscopy. Electrical activity was recorded, using a commercially available cardiac electrophysiologic recording system, before and during pacing at 0.5-3.0 Hz.
RESULTS: Apparent spontaneous electrical depolarizations were detected in both the trigone and the dome. The amplitude of these depolarizations was in the microVolt range. During pacing, local electrical capture was noted in the trigone, but not in the dome.
CONCLUSIONS: Spontaneous low-amplitude electrical activity was detected in the bladder through the use of commercially available cardiac electrophysiology equipment. While these low-level signals could represent noise, the voltage, and morphology resemble detrusor muscle action potentials previously seen in animal studies. Pacing induced local electrical capture in the trigone but not the dome.
PMID: 27494644 [PubMed - as supplied by publisher]
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August 6, 2016

Review of “The Nurse Practitioner in Urology”

Review of “The Nurse Practitioner in Urology”


Hollander, J.B. Int Urol Nephrol (2016). doi:10.1007/s11255-016-1374-0
Urology - Book review

There is a great need in the world for skilled urologic practitioners. Urology physician extenders such as nurse practitioners, physician assistants and specialty trained medical assistants will be needed more and more in order to deliver timely and appropriate care to urologic patients. The office practice manual “The Nurse Practitioner in Urology” is now available and has the potential to become a main resource for office practice in urology. Written by urology nurse practitioners with over 32 years of urologic experience between them, the book serves as a guide for physician extenders in order to provide expert high quality cost effective care for adult urology patients. The book to me is so well written and practical that it may serve as a resource for office urologists themselves. The chapter highlights pertinent pathophysiology, assessment and diagnostics specific to GU conditions and promotes advanced critical thinking for physician extenders specializing in urology. The chapters are written with clinical pearls and practical resources that may be of value not only to physician extenders, but clinicians and patients themselves. In addition to standard outpatient management of both benign and malignant urological conditions, there are chapters on transitioning pediatric urology patients to adult environments, men’s health including low testosterone, erectile dysfunction and infertility, and newer concepts with regard to urinary retention and underactive bladder. The book emphasizes evidence based medicine and the resources necessary to practice in that fashion. The book is user friendly and easy to navigate. “The Nurse Practitioner in Urology” will be a valued asset to all mid-level providers, physician extenders and specialists in the office based practice in urology. I suspect it will be a valued asset to busy state-of-the-art urological offices.

© Springer Science+Business Media Dordrecht 2016

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