Estudo e prevalência de bexiga neurogênica em pessoas com lesão medular traumática e não traumática no Brasil / Study and prevalence of neurogenic bladder in users with traumatic and non-traumatic spinal cord injury in Brazil

A bexiga neurogênica, frequentemente associada à lesão medular de causa traumática e não traumática, é uma disfunção vesical decorrente de alterações no sistema nervoso. Este estudo investigou e analisou a bexiga neurogênica, sua prevalência e manejo em pessoas com diagnóstico de lesão medular traumática (LMT) e não traumática (LMNT) em uma rede de hospitais de reabilitação. Tratou-se de um estudo quantitativo, transversal, exploratório, descritivo e analítico. Para responder à questão central do estudo, foi selecionada uma amostra com 954 participantes, probabilística, aleatória estratificada, das seis unidades da rede participantes do estudo, com dados coletados diretamente dos prontuários eletrônicos. A prevalência de bexiga neurogênica foi de 94,65% (n=903), 67% tinham diagnóstico de lesão medular traumática e 33% de lesão medular não traumática, 69,32% eram homens e 30,68%, mulheres, com média de idade de 46,12 anos (DP=13,26). O cateterismo vesical intermitente foi a principal forma de esvaziamento (66,11%), e a maioria realizava o autocateterismo intermitente (74,04%). A micção voluntária foi associada ao tipo de lesão, sendo mais prevalente entre os participantes com LMNT (p≤0,001, Teste Qui-quadrado). Para investigação urológica, 93,36% realizaram exames de ultrassonografia renal e vias urinárias e 87,82%, estudo urodinâmico. A irregularidade da parede vesical (p≤0,029, teste Qui-quadrado de Pearson), o espessamento vesical (p ≤ 0,001, teste Qui-quadrado de Pearson) e a hiperatividade detrusora (p≤0,009, teste Qui-quadrado de Pearson) também apresentaram diferença estatística de acordo com o tipo de lesão, mais prevalentes nos participantes com LMT. Assim como a dilatação pielocalicinal, mais prevalente nos participantes com LMNT (p≤0,025, teste Qui-quadrado de Pearson). Os participantes com LMT apresentaram maior pressão detrusora média, 38,73cmH2O vs. 30,17cmH2O do que os com LMNT (p ≤ 0,001, teste de Mann- Whitney). Sabe-se que a bexiga neurogênica de pessoas com lesão medular traumática tende a apresentar maior número de complicações e maior risco para o trato urinário superior, principalmente quando há relação com a presença de pressão elevada, baixa complacência e capacidade vesical reduzida. Este estudo evidenciou diferenças importantes entre o perfil de pessoas com lesão medular traumática e não traumática, mostrando a necessidade do manejo personalizado de acordo com a causa da lesão medular.

Neurogenic bladder is a dysfunction that results from changes in the nervous system, and is frequently associated with traumatic and non-traumatic spinal cord injuries. This study investigated and analyzed the neurogenic bladder, its prevalence and management in people diagnosed with traumatic spinal cord injury (TSCI) and non-traumatic spinal cord injury (NTSCI) in a network of rehabilitation hospitals. This is a quantitative, transversal, exploratory, descriptive and analytical study. A probabilistic, stratified random sample, composed of 954 participants, was used to answer the research question. Participants were selected from six of the hospital-network units and data were directly retrieved from electronic medical records. The prevalence of neurogenic bladder was 94.65% (n = 903), where 67% had a diagnosis of traumatic spinal cord injury and 33% non-traumatic spinal cord injury, 69.32% were male and 30.68% female, with a mean age of 46.12 years (SD = 13.26). The main draining method was intermittent bladder catheterization (66.11%), in most cases performed as intermittent self-catheterization (74.04%). Voluntary urination was associated with the type of injury, being more prevalent among participants with non-traumatic spinal cord injury (NTSCI) (p≤0.001, Chi- Square Test). For urological investigation, 93.36% of the participants were submitted to a renal and urinary-tract ultrasound scan and 87.82% to urodynamics. Bladder wall irregularity (p≤0.029, Pearson's chi-square test) and thickening (p ≤ 0.001, Pearson's chi-square test), and detrusor hyperactivity (p≤0.009, Pearson's chi-square test) also presented a statistical difference according to the type of injury, with a higher prevalence in participants with traumatic spinal cord injury (TSCI). That was also the case of pyelocaliceal dilation, which was more prevalent in participants with NTSCI (p≤0.025, Pearson's Chi-square test). Participants with TSCI showed a mean detrusor pressure of 38.73 cmH2O, higher than the value of 30.17 cmH2O recorded for those with NTSCI (p ≤ 0.001, Mann-Whitney test). It is known that a neurogenic bladder in people with traumatic spinal cord injury tends to have a greater number of complications and greater risk for the upper urinary tract, especially when there is a relationship with the presence of high pressure, low compliance and reduced bladder capacity. This study unveiled important differences in the profiles of people with traumatic and non-traumatic spinal cord injury, highlighting the need for treatment to be tailored according to the cause of the spinal cord injury.

Infecciones urinarias en niños con vejiga neurogénica y los patrones de resistencia a los uropatógenos más frecuentes / Urinary tract infections in children with neurogenic bladder and resistance patterns of most frequent urological pathogens

Las infecciones del tracto urinario (ITU) en niños con vejiga neurogénica, pueden producir alteraciones tanto morfológicas como funcionales, y desencadenan una respuesta inmune que no siempre es evidente. Las ITU son una de las principales causas de morbilidad y mortalidad. Resulta de suma importancia un correcto diagnóstico de las mismas, para un buen tratamiento y así evitar las complicaciones y secuelas que puedan ocasionar. El objeto del trabajo fue analizar la prevalencia y la etiología de las ITU en pacientes con vejiga neurogénica, y su patrón de resistencia. En un estudio descriptivo, retrospectivo se incluyeron 46 muestras de orina para cultivo de niños de 1 a 18 años, de ambos sexos, con vejiga neurogénica, que fueron procesadas en un laboratorio de microbiología. De 46 urocultivos, 19 correspondieron a varones (19/46) 41% y 27 a niñas (27/46) 59%, los niños tenían una edad promedio de 11(2. De estos 21 resultaron positivos (21/46) 46%, aislando en mayor proporción E. coli. La frecuencia de ITU en niños con vejiga neurogénica fue de 21/46, 46%, siendo el porcentaje en este tipo de pacientes mucho más elevado que en niños que no presentan dicha anomalía. Los uropatógenos aislados con mayor frecuencia fueron E coli y K pneumoniae. El uso de sondas y pañales, así como la mala higiene predisponen a estas infecciones. En este estudio se vio buena sensibilidad a la nitrofurantoina y cefixima(AU)

Intradetrusor onabotulinumtoxinA injections are significantly more efficacious than oral oxybutynin for treatment of neurogenic detrusor overactivity: results of a randomized, controlled, 24-week trial / Injeções intradetrusoras de onabotulinumtoxinA são significativamente mais eficazes que oxibutinina oral para tratamento da hiperatividade detrusora neurogênica: resultados de estudo randomizado e controlado de 24 semanas

ABSTRACT Objective To prospectively compare the results of intradetrusor onabotulinumtoxinA injections and oral oxybutynin for urinary continence, urodynamic parameters and quality of life in patients with neurogenic detrusor overactivity due to spinal cord injury. Methods Adult patients under intermittent catheterization were randomized 1:1 to receive one injection of onabotulinumtoxinA 300U or oxybutynin 5mg, per oris, three times/day. Primary study endpoint was change in urinary incontinence episodes/24 hours and secondary study endpoints were maximum cystometric capacity, maximum detrusor pressure, bladder compliance and quality of life before randomization and at week 24. Results Sixty-eight patients participated in the trial. Significant improvements in urinary incontinence per 24 hours, all investigated urodynamic parameters and quality of life were observed in both groups. Compared with oral oxybutynin, onabotulinumtoxinA was significantly more efficacious for all parameters investigated. Non-response to treatment was higher for oral oxybutynin (23.5%) than onabotulinumtoxinA (11.8%). Dry mouth was the most common adverse in patients with oral oxybutynin (72%) and transient macroscopic hematuria in patients with onabotulinumtoxinA (28%). Only one patient with oral oxybutynin dropped out the study because of adverse effects. Conclusion The comparison of the two study drugs showed that onabotulinumtoxinA was significantly more efficacious than oral oxybutynin with regard to continence, urodynamic parameters and quality of life. Clinicaltrials.gov: NCT:01477736.

RESUMO Objetivo Comparar prospectivamente os resultados de injeções intradetrusoras de onabotulinumtoxinA e oxibutinina oral em pacientes com hiperatividade neurogênica do detrusor devido à lesão da medula espinhal, para avaliar a continência urinária, os parâmetros urodinâmicos e a qualidade de vida. Métodos Pacientes adultos em cateterismo intermitente foram randomizados 1:1 para tratamento com uma injeção de onabotulinumtoxinA 300U ou oxibutinina 5mg via oral, três vezes por dia. O desfecho primário foi alteração nos episódios de incontinência urinária em 24 horas, e os secundários foram capacidade cistométrica máxima, pressão máxima do detrusor, complacência vesical e qualidade de vida antes da randomização e na 24ª semana. Resultados Participaram do estudo 68 pacientes. Observou-se melhora significativa na incontinência urinária por 24 horas em todos os parâmetros urodinâmicos investigados e na qualidade de vida em ambos os grupos. Em comparação com a oxibutinina oral, a onabotulinumtoxinA foi significativamente mais eficaz para todos os parâmetros investigados. A falha no tratamento foi maior para oxibutinina oral (23,5%) em comparação com onabotulinumtoxinA (11,8%). A boca seca foi o evento adverso mais comum em pacientes tratados com oxibutinina oral (72%), e a hematúria macroscópica transitória naqueles tratados com onabotulinumtoxinA (28%). Apenas um paciente tratado com oxibutinina oral interrompeu o estudo por conta dos efeitos adversos. Conclusão A comparação dos dois fármacos do estudo mostrou que onabotulinumtoxinA foi significativamente mais eficaz que oxibutinina oral em relação a continência, parâmetros urodinâmicos e qualidade de vida. Clinicaltrials.gov: NCT:01477736.

Early treatment improves urodynamic prognosis in neurogenic voiding dysfunction: 20 years of experience / Tratamento precoce melhora o prognóstico urodinâmico na disfunção miccional de origem neurogênica: 20 anos de experiência

Abstract Objective: To evaluate the association between early treatment and urodynamic improvement in pediatric and adolescent patients with neurogenic bladder. Methodology: Retrospective longitudinal and observational study (between 1990 and 2013) including patients with neurogenic bladder and myelomeningocele treated based on urodynamic results. The authors evaluated the urodynamic follow-up (bladder compliance and maximum bladder capacity and pressure) considering the first urodynamic improvement in two years as the outcome variable and early referral as the exposure variable, using a descriptive and multivariate analysis with logistic regression model. Results: Among 230 patients included, 52% had an early referral. The majority were diagnosed as overactive bladder with high bladder pressure (≥40 cm H2O) and low bladder compliance (3 mL/cmH2O) and were treated with oxybutynin and intermittent catheterization. Urodynamic follow-up results showed 68% of improvement at the second urodynamic examination decreasing bladder pressure and increasing bladder capacity and compliance. The percentage of incontinence and urinary tract infections decreased over treatment. Early referral (one-year old or less) increased by 3.5 the probability of urodynamic improvement in two years (95% CI: 1.81-6.77). Conclusion: Treatment onset within the first year of life improves urodynamic prognosis in patients with neurogenic bladder and triplicates the probability of urodynamic improvement in two years. The role of neonatologists and pediatricians in early referral is extremely important.

Resumo Objetivo: Avaliar a associação entre tratamento precoce e melhoria urodinâmica em pacientes pediátricos e adolescentes portadores de bexiga neurogênica. Metodologia: Estudo observacional longitudinal retrospectivo (entre 1990-2013) em pacientes com bexiga neurogênica e mielomeningocele tratados com base no diagnóstico urodinâmico. Avaliamos a evolução urodinâmica (complacência, capacidade e pressão vesical) e consideramos primeira melhoria urodinâmica em até dois anos como variável desfecho e encaminhamento precoce (primeira urodinâmica até um ano de vida) como exposição. Foi feita análise descritiva e multivariada com modelo de regressão logística. Resultados: Entre 230 pacientes incluídos 52% foram encaminhados precocemente. A maioria tinha bexiga hiperativa com pressão maior do que 40 cmH2O, complacência abaixo de 3 ml/cmH2O e foi tratada com oxibutinina e cateterismo intermitente. Na evolução urodinâmica, 68% apresentou melhoria já no segundo exame com redução da pressão e aumento da capacidade e da complacência vesical. O percentual de incontinência e infecção urinária diminuiu ao longo do tratamento. O encaminhamento precoce aumentou 3,5 vezes a probabilidade de melhoria urodinâmica até dois anos em relação aos encaminhados após o primeiro ano de idade (CI95% 1,81-6,77). Conclusão: Tratar no primeiro ano de vida melhora o prognóstico urodinâmico de pacientes com bexiga neurogênica, triplica a probabilidade de melhoria urodinâmica em até dois anos. A atuação do neonatologista e do pediatra, ao reconhecer e encaminhar o paciente precocemente para o diagnóstico, é extremamente importante.

Rol de onabotulinumtoxin A en el tratamiento de niños con vejiga neurogénica / The rol of Onabotulinumtoxin A in the treatment of children with a neurogenic bladder

Introducción: Onabotulinumtoxina es una alternativa terapéutica de segunda línea en pacientes sin respuesta a los anticolinérgicos. Objetivo: Evaluar los efectos de repetidas inyecciones de onabotulinumtoxina en vejigas neurogénicas refractarias al tratamiento clásico. Pacientes y métodos: Se evaluaron 82 pacientes menores de 18 años con vejiga neurogénica, en su mayoría por disrafia espinal. Todos fueron refractarios a oxibutinina oral. Si luego del tercer mes de la primer inyección en el detrusor se constataba mejoría clínica y/o urodinámica; se reinyectaban entre los 9 y 12 meses, nuevamente. De lo contrario, se indicaba cistoplastia de aumento. En algunos casos se utilizaron otros procedimientos endoscópicos - quirúrgicos accesorios. Resultados: Se reinyectaron con Onabotulinumtoxina, dos, tres, cuatro y cinco veces: 20 casos, 7, 4 y un caso, respectivamente. En el 51% promedio se logró continencia urinaria total (score cero-seco). En la primera y segunda inyección hubo incremento significativo en la media de capacidad cistométrica: de 254 a 331 ml (p: 0.007) y de 257 a 367 ml (p: 0.014); respectivamente. En algunos casos, luego de la primer inyección mejoró significativamente la compliance: de 6,9 a 11,4 ml/cmH2O (p: 0.05). La media de presión del detrusor al final del llenado disminuyó en promedio de 37 a 34,4 cmH2O. La sobreactividad del detrusor (n:22) se atenuó en el 54,4% luego de la primer inyección. No se registraron efectos adversos mayores con las reinyecciones. En 15 pacientes refractarios a OnabotulinumtoxinA se realizó ampliación vesical. Conclusión: Luego del tratamiento con onabotulinumtoxina, la continencia urinaria alcanzada fue del 50% promedio. La capacidad cistometrica se incrementó significativamente con las dos primeras inyecciones; aunque no se acompañó paralelamente de un importante descenso de presiones endovesicales. El uso de onabotulinumtoxina ha logrado suprimir o retrasar la clásica indicación de cistoplastia de aumento en niños refractarios a los anticolinérgicos (AU)

Introduction: OnabotulinumtoxinA is a second-line alternative therapy for patients who do not respond to anticholinergics. Aim: To evaluate the impact of repeated injections of OnabotulinumtoxinA in neurogenic bladders refractory to conventional treatment. Patients and methods: 82 patients younger than 18 years with a neurogenic bladder, in the majority due to spinal dysraphism, were evaluated. All were refractory to oral oxybutynin. If in the third month after the first injection in the detrusor clinical and/or urodynamic improvement was observed, between 9 and 12 months later a second injection was given. If not, augmentation cystoplasty was indicated. In some cases other endoscopic/surgical procedures were used. Results: Twenty, seven, four, and one case were reinjected with OnabotulinumtoxinA, two, three, four, and five times, respectively. In a mean of 51% of the patients total urinary continence was achieved (score zero - completely dry). On the first and second injection a significant increase of the maximum cystometric capacity was observed: from 254 to 331 ml (p: 0.007) and from 257 to 367 ml (p: 0.014), respectively. In some cases, after the first injection compliance improved significantly: from 6.9 to 11.4 ml/cmH2O (p: 0.05). Mean end filling detrusor pressure diminished from 37 to 34.4 cmH2O. Detrusor overactivity (n: 22) attenuated in 54.4% after the first injection. No major adverse effects were recorded after the reinjections. In 15 patients that were refractory to OnabotulinumtoxinA augmentation cystoplasty was performed. Conclusion: After OnabotulinumtoxinA treatment, 50% urinary continence was achieved. Cystometric capacity increased significantly after the first two injections; however, it was not associated with an important decrease of intravesical pressure. The use of OnabotulinumtoxinA may avoid or delay the classical indication of augmentation cystoplasty in anticholinergicrefractory children (AU)

Efficacy, Tolerability, and Safety of Oxybutynin Chloride in Pediatric Neurogenic Bladder With Spinal Dysraphism: A Retrospective, Multicenter, Observational Study

PURPOSE: Anticholinergics are a key element in treating neurogenic detrusor overactivity, but only limited data are available in the pediatric population, thus limiting the application to children even for oxybutynin chloride (OC), a prototype drug. This retrospective study was designed to provide data regarding the efficacy, tolerability, and safety of OC in the pediatric population (0-15 years old) with spinal dysraphism (SD). MATERIALS AND METHODS: Records relevant to OC use for neurogenic bladder were gathered and scrutinized from four specialized clinics for pediatric urology. The primary efficacy outcomes were maximal cystometric capacity (MCC) and end filling pressure (EFP). Data on tolerability, compliance, and adverse events (AEs) were also analyzed. RESULTS: Of the 121 patient records analyzed, 41 patients (34%) received OC at less than 5 years of age. The range of prescribed doses varied from 3 to 24 mg/d. The median treatment duration was 19 months (range, 0.3-111 months). Significant improvement of both primary efficacy outcomes was noted following OC treatment. MCC increased about 8% even after adjustment for age-related increases in MCC. Likewise, mean EFP was reduced from 33 to 21 cm H2O. More than 80% of patients showed compliance above 70%, and approximately 50% of patients used OC for more than 1 year. No serious AEs were reported; constipation and facial flushing consisted of the major AEs. CONCLUSIONS: OC is safe and efficacious in treating pediatric neurogenic bladder associated with SD. The drug is also tolerable and the safety profile suggests that adjustment of dosage for age may not be strictly observed.

Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients

PURPOSE: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. MATERIALS AND METHODS: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). RESULTS: 77 percent of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46 percent of the patients were in the "full success" group. 31 percent of the patients had a partial improvement. 23 percent of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). CONCLUSIONS: Despite that a full success was obtained in 46 percent of the cases, BTX-A injection therapy failed to treat refractory NDO in 23 percent of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anticholinergic drugs fail to reduce NDO.

Botulinum toxin A in the treatment of spinal cord injury patients with refractory neurogenic detrusor overactivity

PURPOSE: To evaluate the efficacy of botulinum toxin type A injections in the detrusor muscle in patients with spinal cord injury and urinary incontinence due to detrusor overactivity and refractory to anticholinergic agents. MATERIALS AND METHODS: We prospectively evaluated 22 patients with spinal cord injuries, whose bladders were emptied by intermittent catheterization. All patients had detrusor overactivity and urinary incontinence that proved difficult to treat, despite using high doses of two different anticholinergics. The pre-treatment assessment included a complete urodynamic study and ultrasonography of the kidneys and urinary tract. A one-month follow-up was completed with urodynamic evaluation and the clinical response was evaluated through outpatient consultations and telephone contact. RESULTS: After the procedure, the maximum cystometric capacity and the bladder reflex volume increased, whereas the maximum detrusor pressure and compliance decreased. The mean duration of continence was 7 ± 7 months. In 18 patients (81.8 percent), it was necessary to administer anticholinergics to achieve continence. Five patients (22.7 percent) had indication of reinjection, and augmentation cystoplasty was indicated in 9 patients (40.9 percent). CONCLUSION: The use of botulinum toxin in the treatment of neurogenic detrusor overactivity refractory to anticholinergics is an option before more invasive treatments, such as augmentation cystoplasty, are attempted. In our study as well as in the literature, there was improvement in most urodynamic parameters. Overall, 40.9 percent of patients underwent augmentation cystoplasty and 81.8 percent of patients needed anticholinergic agents to reach urinary continence. Further studies are necessary to improve the procedure and to achieve better clinical results.

Experience with different botulinum toxins for the treatment of refractory neurogenic detrusor overactivity

Purpose: To report our experience with the use of the botulinum toxin-A (BoNT/A) formulations Botox® and Prosigne® in the treatment of neurogenic detrusor overactivity (NDO). Materials and methods: At a single institution, 45 consecutive patients with refractory urinary incontinence due to NDO received a single intradetrusor (excluding the trigone) treatment with botulinum toxin type A 200 or 300 units. Botox was used for the first 22 patients, and Prosigne for the subsequent 23 patients. Evaluations at baseline and week 12 included assessment of continence and urodynamics. Safety evaluations included monitoring of vital signs, hematuria during the procedure, hospital stay, and spontaneous adverse event reports. Results: A total of 42 patients were evaluated (74 percent male; mean age, 34.8 years). Significant improvements from baseline in maximum cystometric capacity (MCC), maximum detrusor pressure during bladder contraction, and compliance were observed in both groups (P < 0.05). Improvement in MCC was significantly greater with Botox versus Prosigne (+103.3 percent vs. +42.2 percent; P = 0.019). Continence was achieved by week 12 in 16 Botox recipients (76.2 percent) and 10 Prosigne recipients (47.6 percent; P = 0.057). No severe adverse events were observed. Mild adverse events included 2 cases of transient hematuria on the first postoperative day (no specific treatment required), and 3 cases of afebrile urinary tract infection. Conclusions: Botox and Prosigne produce distinct effects in patients with NDO, with a greater increase in MCC with Botox. Further evaluation will be required to assess differences between these formulations.

The use and rationale of selective alpha blockade in children with non-neurogenic neurogenic bladder dysfunction

INTRODUCTION: We present here a long-term observation of 2 children with a rare syndrome with a non-neurogenic neurogenic bladder dysfunction (Hinman's syndrome), and we investigated the safety and efficacy of long-term use of terazosine in association with prophylactic antibiotics, timed voiding and a bowel regimen. MATERIALS AND METHODS: Two children, 7 years-old (22 kg) and 11 years-old (36 kg) presented in 1997 to our pediatric urology clinic with symptoms of urgency, frequency, urge incontinence and nocturnal enuresis. Both children were placed in a regimen of terazosine (starting with 0.5 mg increasing until 2 mg). RESULTS: There were no significant side effects throughout the entire treatment. The first 7-year old boy however developed some dizziness when the dose of terazosine was increased to 2 mg (after 4 weeks of administrating 1 mg), and this disappeared immediately when the dosage was reduced back to 1 mg daily. The urgency symptoms improved in both boys after 3 weeks of 1 mg terazosine. The secondary enuresis in the 11 year-old boy resolved after 2 months of 2 mg terazosine. CONCLUSION: It is possible to say that the alpha-blocker medication, terazosine can be administered safely to children with a non-neurogenic bladder dysfunction, also known as the Hinman's syndrome. These results have shown that dysfunctional voiding, postvoiding residual and upper tract involvement can disappear over time when long term terazosine is given in combination with timed voiding, prophylactic antibiotic therapy and treatment of the associated constipation. Our observations also suggest a permanent effect after discontinuing the medication.

Effects of Ylang-Ylang Essential Oil on the Relaxation of Rat Bladder Muscle in vitro and White Rabbit Bladder in vivo

Current and primary treatment modality in overactive bladder includes the administration of anticholinergics. The demand for new agents has been rising since anticholinergics have proven to come with many side effects. This study was designed to investigate the effects of ylang-ylang essential oil (YYEO) on the relaxation of urinary bladder muscle in vitro and in vivo. Effects of YYEO were assessed on resting tension, and electrical field stimulation- and various drug-induced contraction in vitro by checking the isometric tension changes of muscle strips and same procedures were repeated in the presence of methylene blue, Nw-Nitro-L-arginine methyl ester hydrochloride (L-NAME), or N-ethylmaleimide, and in vivo. YYEO decreased significantly the contractility of strips. There was no statistically significant difference between the treated group only with YYEO and the pretreated group with YYEO and methylene blue or L-NAME. When N-ethylmaleimide was employed, there was a statistically significant decrease in the rate of contraction. In vivo studies showed the same results compared with in vitro study. The results of this study indicate that YYEO has a relaxing effect on the bladder, and such mechanism is thought to be brought about by a pathway mediated by c-AMP.

Evaluación de la efectividad y tolerancia de la oxibutinina en el tratamiento de la vejiga inestable en la mujer / Oxybutynin in the treatment of unstable bladder: effectiveness and tolerability evaluation

La vejiga inestable es un síndrome frecuente en pacientes femeninas y debido a contracciones involuntarias del músculo detrusor; principalmente debidas a denervación de musculatura lisa vesical que genera hipersensibilidad miccional con pérdida del control cortical inhibitorio. Clínicamente se manifiesta en aumento de frecuencia urinaria, nicturia, urgencia miccional e incontinencia urinaria de urgencia. El tratamiento más efectivo históricamente ha sido el uso de miorrelajantes y anticolinérgicos. Presentamos un estudio prospectivo, doble ciego, cruzado y controlado con placebo para evaluar eficacia y tolerancia de la oxibutinina en mujeres con vejiga inestable. Se incluyeron 44 mujeres adultas con vejiga inestable, 22 de ellas recibieron oxibutinina 5 mg tres veces al día y 22 placebo 5 mg tres veces al día en forma aleatoria en ambos grupos durante seis semanas, al término de las cuales se realizó lavado y a las que recibieron inicialmente oxibutinina se les administró placebo a las que inicialmente recibieron placebo se les administró oxibutinina, durante seis semanas más. Cinco pacientes que iniciaron el estudio con oxibutinina abandonaron el estudio, dos de ellas por intolerancia al medicamento y tres por causas desconocidas. Un total de 74 sujetos (37 para cada brazo del estudio) tuvieron promedio de edad de 51.7 años. La puntuación de síntomas disminuyó de 13 a 11 y de 13 a 6 puntos con placebo y oxibutinina respectivamente (p= 0.001). La escala análoga visual de síntomas disminuyó de 77 por ciento a 62.5 por ciento y 40 por ciento con placebo y oxibutinina respectivamente (p= 0.003). La tasa de mejoría global evaluada a través de puntuación de síntomas fue de 27 por ciento con placebo y de 72.9 por ciento con oxibutinina (p= 0.000) evaluada a través de escala análoga visual de síntomas fue de 40 por ciento para el placebo y 78.3 por ciento para la oxibutinina (p= 0.002). El volumen vesical al primer deseo miccional, aumentó de 129 mL a 134 mL y 187 mL con placebo y oxibutinina respectivamente (p= 0.021) la capacidad cistométrica máxima aumentó de 231 a 236 y 301 mL con placebo y oxibutinina respectivamente (p= 0.008). El efecto colateral más frecuente en ambos grupos fue sequedad de boca y se presentó en 6 (19 por ciento) y 34 (91 por ciento) pacientes con placebo y oxibutinina respectivamente (p= 0.000). Sólo 5 de 44 pacientes (11.3 por ciento) con oxibutinina y dos de 44 pacientes (4.4 por ciento) con placebo abandonaron el estudio (p= 0.14)

Oxibutinina intravesical / Intravesical oxybutynin

Os autores apresentam o caso de uma criança com bexiga neurogênica hiper-reflexa secundária a mielomeningocele, tratada inicialmente com oxibutinina por via oral e cateterismo intermitente, com bons resultados durante 18 meses. Após este período, a paciente desenvolveu náuseas e constipaçäo intestinal severa. A substituiçäo da medicaçäo oral pela via intravesical obteve bons resultados terapêuticos, com o desaparecimento dos efeitos colaterais

Inestabilidad vesical, tratamiento con cloruro de oxibutinina / Instability of the urinary bladder: treatment with oxibutinine chloride

Se trató con cloruro de oxibutinina, una muestra 40 pacientes con inestabilidad vesical, diagnosticada desde los puntos de vista clínico y urodinámico. A todos se les administró de 10-15 mgs./día de cloruro de oxibutinina, por una media de 12 meses (8-18 meses). El tratamiento y seguimiento, fue valorado tras un período de 6-38 meses (media de 20 meses). Desde el punto de vista clínico se obtuvo mejoría total en un plazo de tratamiento de 3 meses, en 20 pacientes (50/100) mejoría relativa con desaparición de algunos de los síntomas o disminución de intensidad de los previos en 18(45/100). No se obtuvo mejoría en 2 pacientes (5/100) Obtuvimos una mejoría global y relativa del 95/100. Desde el punto de vista urodinámico, desaparecieron los signos de inestabilidad de forma total en los 5 pacientes en que se efectuó control urodinámico. Entre los efectos secundarios encontrados, 38 pacientes manifestaron sequedad de boca, 5 pacientes náusea y vómitos, en 10 casos fue necesario reducir la dosis diaria de 15 a 10 mg.

Efecto del núcleo CMP forte en 46 pacientes con paraparesia espástica progresiva: estudio randomizado y ciego / Effect of CMP forte nucleus in 46 patients with progressive spastic paraparesis: randomized and blind study

Idiopatic or HTLV-1 associated progressive spastic paraparesis does not have a clear etiology or treatment. To assess the effects of a medication containing cytidinmonophosphate, uridintriphosphate and vitamin B 12 in the treatment of progressive spastic. Patients with the disease were randomly assigned to receive the Nucleus CMP forte (containing dysodic cytidinmonophosphate 5 mg,trisodic uridintriphosphate 3 mg and hydroxicobalamin 2 mg) tid or placebo during 6 months. Gait, spasticity, degree of neurogenic bladder and somatosensitive evoked potentials were assessed during treatment. Forty six patients aged 25 to 79 years old were studied, 24 were female and 29 HTLV-1 positive. Twenty two were treated with the drug and the rest with placebo. Gait and spasticity improved in 7 of 22 patients receiving the drug and 1 of 24 receiving placebo (p<0.05). Neurogenic bladder improved in 10 of 22 receiving the drug and 4 patients treated with the drug and in two of seven treated with placebo. The medication caused a modest improvement in patients with progressive spastic paraparesis and was free of side effects