Brain imaging and urodynamic correlation in patients with cerebrovascular stroke

Objective: To identify urodynamic abnormalities in patients with cerebrovascular accidents and correlate both with CT or MRI findings. Patients and Methods: From September 2001 to March 2003; a total of 44 males and 16 females were prospectively examined urodynamically in different phases after cerebrovascular accidents; and as early as two days after stroke. Results: In most cases; the urodynamic findings could be correlated with CT or MRI findings. The most determining factor was the site of the lesion followed by the size. Small lesions were frequently silent unless located in critical sites. It was found that frontal; frontoparietal; parietal; basal ganglia and internal capsular ischemic lesions were associated in most cases with detrusor hyperreflexia; whereas thalamic; pontine and cerebellar infarcts were linked to detrusor hyporeflexia. Multiple lesions within the same group produced the same effect; while mixed lesions produced variable ef-fects. There was no effect of laterality or dominance and an initial shock phase could not be identified. Detrusor-sphincter-dys-synergia (DSD) and hence upper tract deterioration were not observed. The effect of stroke was also modified by already present or predominant conditions such as BPH. Conclusion: Correlating urodynamic and CT findings is very difficult in stroke patients because of the diffuse nature of the lesions; the unknown function of many brain centers in micturition control; the innumerable connections between the different brain regions and the extremely complicated influences that the brain regions exert upon each other and upon the bladder. The optimal understanding of the problem is dependent upon the better understanding of the function of each part of the brain. Further studies in this direction are recommended

The Impact of preservation of the prostatic apex on the urodynamic characteristics in different orthotopic ileal reservoirs

Objective This study was carried out to evaluate the urodynamic characteristics of the Camey II; Kock's and W-configured ileal reservoirs utilized for orthotopic urinary diversion. Patients and Methods Between January 2000 and 2002; 42 male patients prospectively underwent radical cystoprostatectomy for bladder cancer followed by orthotopic urinary diversion at the urology department of Cairo University hospitals. All cases were evaluated clinically; bacteriologically; radiologically and urodynamically including uroflowmetry; medium-fill and voiding enterocystometry and urethral pressure profilometry; which was done in the early and late postoperative period (at 3-6 months and 6-18 months). Patients were divided into four groups: Group I: 11 cases with preservation of the prostatic apex and creation of a W-neobladder. Group II: 11 cases without prostatic apex preservation and creation of a W-shaped ileal pouch. Group III: 12 cases without prostatic apex preservation and creation of a Camey II pouch. Group IV: 8 cases without prostatic apex preservation and creation of a Kock's pouch. Results The patients of Group I had a larger mean neobladder capacity (699 ml) and volume at which the first contraction occurred (315 ml) and a larger amount of residual urine (224 ml) as compared to Group II (511.1; 285 and 77.5 ml; respectively); Group III (375; 200 and 55 ml; respectively) and Group IV (563; 266 and 600 ml; respectively). Also Group I with a preserved prostatic apex had a higher mean intraluminal opening pressure (55 cm H2O) and a higher pressure at maximum flow (62.36 cm H20) as compared to the patients with complete prostatic resection. Conclusion We conclude that the patients with a preserved prostatic apex (Group I) had a statistically significant higher mean residual urine in the early and late postoperative period and a significantly higher mean maximum cystometric capacity in the late postoperative period as compared to those recorded in patients with complete prostatic resection (Groups II; III; IV). A higher incidence of upper tract deterioration was detected in Group I (35) vs. 4.6; 27.8and 12.5in Groups II; III and IV; respectively

Urodynamic assessment of sacral root neuromodulation in patients with intractable storage and voiding dysfunctions

Objective Sacral root neuromodulation is becoming one of the standard options for the treatment of intractable voiding dysfunction. The current report presents the urodynamic changes supporting the subjective improvement achieved by sacral root neuromodulation in patients with both voiding and storage problems. Patients and Methods Out of 50 patients being candidates for peripheral nerve evaluation (PNE) for various voiding and storage problems; 38 patients agreed to be subjected to urodynamics before; during and after subchronic PNE. Seventeen patients presented with an urgency-frequency syndrome; 9 with urge incontinence and 12 with chronic idiopathic urinary retention. All patients had failed to respond to various previous oral and intravesical treatments. The protocol included a four-day voiding diary and urodynamics before; during and after subchronic PNE. Results Significant changes in the urodynamic results of the patients during PNE were noted. Urodynamics of the urge incontinence and urgency-frequency patients showed an increased volume compared to the first urge cystometric bladder capacity after sacral root neuromodulation. The cystometrograms of patients with chronic idiopathic urinary retention did not show any difference during PNE when compared to the pre-PNE tests. Pressure-flow studies that were not possible before PNE became normalized during PNE. The urodynamics of all patients one week after PNE showed variable degrees of deterioration. The urodynamic findings of 7 patients who had an implantation of permanent programmers still showed the same results as after PNE testing. Conclusion There is a definite correlation between both subjective and objective improvement of patients on neuromodulation proved by urodynamic studies. However; this needs to be further evaluated as a predictor for success

Urodynamic evaluation of voiding function in females with stress urinary incontinence

Objective The evaluation of voiding function in females with lower urinary tract symptoms (LUTS) with a special emphasis on the evaluation of storage function and the state of continence. Patients and Methods 176 patients were investigated for urinary incontinence-related problems at the Unit for Neuro-Urology and Urodynamics of the Department of Urology; University Medical Center Nijmegen (The Netherlands). The patients were classified into two groups according to their symptoms and urodynamic studies. Group I consisted of 103 patients with stress urinary incontinence (SUI); while Group 2 included 73 patients with other forms of urinary incontinence or no urodynamic abnormalities at all. All patients were subjected to urodynamic investigations including uroflowmetry; static and dynamic urethral pressure profiles; filling cystometry and pressure-flow studies. Results It was noted that the bladder capacity as well as the average and maximum flow rates tended to be higher among patients with SUI. Some insignificant increase in outlet obstruction; as assessed by the Lin PURR nomogram was noticed. Detrusor contractility was only found to be significantly reduced in patients with SUI when the total Watts factor was compared in both groups. Conclusion When comparing both groups; significant differences were found in the filling cystometry as well as in the urethral pressure profile variables. Some differences were also detected with regard to pressure-flow studies and detrusor contractility during voiding

Primary noctural enuresis : a clinical urodynamic. evaluation and analysis of therapeutic options

Objective To assess the clinical evaluation; urodynamic data and therapeutic options in patients with primary nocturnal enuresis. Patients and Methods A total of 473 patients aged between 5 and 35 years were evaluated clinically and underwent urine analysis and cultures as well as plain radiography of the abdomen. Intravenous urography was done when indicated. A urodynamic study was done in patients with polysymptomatic enuresis; a failed previous therapy and enuresis in adults. Initially; patients with monosymptomatic enuresis and those who had polysymptomatic enuresis with a stable detrusor function were managed by conditioning therapy using a calendar. When urodynamic studies detected detrusor instability (DI); the patients were initially treated by anti-muscarinics. Results Monosymptomatic enuresis was diagnosed in 329 patients; while the remaining 144 patients had polysymp-tomatic enuresis. Detrusor instability was detected in 36 of the monosymptomatic patients and in 93 of the polysymptomatic patients. Bladder capacities at the first sensation (FS); at normal sensation and at the maximum cystometric capacity (MCC) showed a statistically significant increase in patients with stable detrusor function compared to those with DI. The detrusor pressure (Pdet) was significantly higher at the first sensation and at the MCC in patients with DI than in patients with a stable detrusor. Conditioning therapy showed satis-factory results in 74of the patients with a better outcome in those with monosymptomatic enuresis. Antimuscarinics treated 91 of both monosymptomatic and polysymptomatic enuretics with DI. Conclusion Conditioning therapy using a calendar can offer a good therapeutic modality to most patients with primary nocturnal enuresis with stable detrusor function avoiding the costs and side effects of drugs. Pharmacotherapy should only be used when this conditioning therapy fails. Filling cystometry can detect detrusor instability as a cause of enuresis that helps in the proper choice of antimuscarinics as a primary line of treatment