Disfunción urinaria en la enfermedad de Parkinson: una revisión práctica / Urinary dysfunction in Parkinson's disease: a practical review

Resumen La enfermedad de Parkinson (EP) es una enfermedad multisistémica de naturaleza neurodegenerativa, que clínicamente se caracteriza por presencia de síntomas motores como bradicinesia, rigidez, temblor en reposo e inestabilidad postural. Sin embargo, también pueden estar presentes síntomas no motores que constituyen trastornos del ánimo, trastornos del sueño, disfunción cognitiva o disfunción autonómica. Dentro de las disfunciones autonómicas, los síntomas urinarios se han documentado en los pacientes con enfermedad de Parkinson. Los síntomas urinarios más comunes son la nicturia, urgencia urinaria, aumento de la frecuencia miccional e incontinencia de urgencia. El presente artículo hace una revisión narrativa de la literatura actual sobre los mecanismos fisiopatológicos, manifestaciones clínicas, diagnóstico y tratamiento de la disfunción urinaria en pacientes con enfermedad de Parkinson.

Parkinson's disease (PD) is a neurodegenerative multisystemic diseases, which is clinically characterized by the presence of motor symptoms such as bradykinesia, rigidity, resting tremor, and postural instability. However, non-motor symptoms constituting mood disorders, sleep disorders, cognitive dysfunction, or autonomic dysfunction may also be present. Within autonomic dysfunctions, urinary symptoms have been documented in patients with Parkinson's disease. The most common urinary symptoms are nocturia, urinary urgency, increased urinary frequency, and urge incontinence. This article makes a narrative review of the current literature on the pathophysiological mechanisms, clinical manifestations, diagnosis and treatment of urinary dysfunction in patients with Parkinson's disease.

Alternativas a la vía transuretral para la inyección de toxina botulínica en esfínter urinario / Botulinum toxin inyection in urinary sphincter: alternative approaches

Objetivo: Presentamos las vías transrectal en varones y transvaginal en mujeres como alternativas a la vía transuretral para la inyección de toxina botulínica (TB) en esfínter urinario, así como nuestros resultados. Material y Método: Se inyectó TB en esfínter urinario a 9 pacientes entre diciembre de 2008 y agosto de 2010para el tratamiento de distintas disfunciones de vaciado refractarias a tratamiento convencional. La vía utilizada fue transrectal en 7 varones y transvaginal en 2 mujeres. Las dosis utilizadas oscilaron entre 50 y200 U. Registramos resultados y complicaciones. Resultados: Obtuvimos resultados satisfactorios en 6pacientes (66 por ciento) según criterios clínicos. La duración del efecto osciló entre los 3 y 7 meses. No registramos complicaciones significativas relacionadas con la inyección y la tolerancia al dolor fue buena. Conclusiones: La vía transrectal en varones y transvaginal en mujeres son alternativas válidas y seguras para la inyección de TB en esfínter urinario.

Objective: To present our institution experience and outcomes with transrectal and transvaginal injection of botulinum toxin (TB) in urinary sphincter to treat voiding disfunction. Material and methods: We injected TB in 9 patients since December 2008 to august 2010 in order to treat different voiding disfunctions. We use the transrectal approach in 7 men and the transvaginal method in 2 women. The dose used ranged from 50 to 200 units. Outcomes and complications were registered. Results: Satisfactory outcomes were obtained in 6 patients (66 pert cent) according to clinical criteria. The duration of the effect was from 3 to 7 months. No major complications were registered and pain was well tolerated. Conclusions: Transrectal and transvaginal approaches are effective and safe for the injection of TB in urinary sphincter.

Efficacy and Safety of Tamsulosin for the Treatment of Non-neurogenic Voiding Dysfunction in Females: A 8-Week Prospective Study

We evaluated the therapeutic effects of tamsulosin for women with non-neurogenic voiding dysfunction. Women who had voiding dysfunctions for at least 3 months were included. Inclusion criteria were age > or =18 yr, International Prostate Symptom Score (IPSS) of > or =15, and maximum flow rate (Q(max)) of > or =12 mL/sec and/or postvoid residuals (PVR) of > or =150 mL. Patients with neurogenic voiding dysfunction or anatomical bladder outlet obstruction were excluded. All patients were classified according to the Blaivas-Groutz nomogram as having no or mild obstruction (group A) or moderate or severe obstruction (group B). After 8 weeks of treatment, treatment outcomes and adverse effects were evaluated. One hundred and six patients were evaluable (70 in group A, 36 in group B). After treatments, mean IPSS, bother scores, Q(max), PVR, diurnal and nocturnal micturition frequencies and scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire (BFLUTS-SF) were changed significantly. Eighty-nine patients (84%) reported that the treatment was beneficial. The proportion of patients reported that their bladder symptoms caused "moderate to many severe problems" were significantly decreased. No significant difference were observed between the groups in terms of IPSS, bother score, Q(max), PVR, micturition frequency, and BFLUTS-SF changes. Adverse effects related to medication were dizziness (n=3), de novo stress urinary incontinence (SUI) (n=3), aggravation of underlying SUI (n=1), fatigue (n=1). Tamsulosin was found to be effective in female patients with voiding dysfunction regardless of obstruction grade.

Gabapentin for overactive bladder and nocturia after anticholinergic failure

INTRODUCTION: We reviewed our experience with the use of gabapentin to treat symptoms of overactive bladder (OAB) and nocturia in patients who have failed conventional anticholinergic therapy. METHODS: Thirty-one patients referred to us with refractory (OAB) and/or nocturia were treated with oral gabapentin. All the patients had tried or remained on antimuscarinic drugs during treatment. Twenty-four of 31 complained of bothersome symptoms during day and night and the other seven had primary complaints of nocturia. Initial gabapentin doses ranged from 100-300 mg at bedtime. Dose was slowly titrated up to 3,000 mg based on patients' symptomatology and tolerability. RESULTS:The mean age was 51 years old (range 27-78). There were 13 men and 18 women. The median steady state dose chosen by the patient after initial titration was 600 mg/day. Fourteen of 31 patients reported subjective improvement of their frequency and 8 have been on the medication for over 12 months with persistent efficacy. For the 14 improved patients, mean frequency/24 hours decreased from 14.1 ± 2.2 to10.0 + 2.1. Three patients with primary nocturia reported improvement from a mean of 4.0 ± 1.3 to 1.0 ± 0.3 episodes/night. Six patients stopped taking the drug within one month due to side effects mostly described as drowsiness or lethargy. CONCLUSION: Fourteen of 31 patients with refractory (OAB) and nocturia improved with oral gabapentin. Gabapentin was generally well tolerated and can be considered in selective patients when conventional modalities have failed.

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.

Resiniferatoxin for detrusor instability refractory to anticholinergics

PURPOSE: We have evaluated the clinical and urodynamic effects of intravesical instillation of resiniferatoxin in patients with idiopathic detrusor instability refractory to anticholinergics. MATERIALS AND METHODS: There were 30 women, median age 56 years old with detrusor instability for over 6 months and a history of anticholinergic use with no response or intolerable collateral effects. A 50 nM solution of resiniferatoxin was prepared for intravesical instillation. All patients were evaluated for urinary symptoms, as well as for urodynamic assessments before and 30 days after instillation. Tolerability was analyzed during the instillation. RESULTS: A clinical improvement was observed in 30 percent of the patients with urinary urgency and in 33 percent of the patients with urge-incontinence. The mean maximum cystometric capacity before application was 303.9 ± 78.9 and after application 341 ± 84.6. No significant difference was observed (p = 0.585). The mean maximum amplitude of the contractions diminished from 47.86 ± 29.64 to 38.72 ± 30.77 (p = 0.002). CONCLUSIONS: Resiniferatoxin, in this concentration, proved to be useful in a small percentage of patients regarding clinical detrusor instability. Maximum amplitude of the involuntary contractions was significantly reduced and in 33 percent patients the involuntary contractions disappeared. Further studies with different concentrations are recommended.

Disúria e polaciúria: sintomas realmente sugestivos de infecção do trato urinário? / Dysuria and polaciuria: really a suggestive symptom of urinary tract infection?

Infecção do trato urinário (ITU) é considerada uma das infecções mais comuns na população, sendo responsável por significativa morbidade no sexo feminino. Na rotina dos consultórios médicos ambulatoriais, o tratamento das ITU não complicadas em mulheres adultas é iniciado com base na anamnese, já que a maioria das ITU é acompanhada por sintomas como disúria e polaciúria. O presente estudo visou determinar a correlação entre os sintomas clássicos de ITU e o diagnóstico efetivo desta patologia, caracterizado pela urocultura positiva, atravé de um inquérito epidemiológico realizado com mulheres com idade entre 15 a 55 anos. Das 191 mulheres avaliadas, 56 (29%) apresentaram sintomas sugestivos de ITU. Das 16 mulheres que apresentaram disúria, 2 (12,5%)tiveram o diagnóstico de ITU confirmnado. A presença de disúria e polaciúria ocorreu em 27 mulheres sendo que 5 (18,5%) destas apresentavam realmente ITU. Os coeficientes de correlação entre disúria, polaciúria e a soma destes sintoma com o resultado da cultura foram inferiores a 0,5, demonstrando que não ocorreu correlação significativa entre estas variáveis. Este estudo sugere que a anamnese não deve ser utilizada como critério único para diagnóstico das ITU e que este deve ser confirmado sempre que possível com exames laboratoriais.

Rosacea, vinagre y limon, disuria y Helicobacter pylori / Rosacea, vinegar and lemon, dysuria and Helicobacter pylori

Varón de 52 años que consulta por presentar disuria, ardor miccional y lesiones cutáneas que mejoran con una alta ingesta diaria de ácidos (vinagre y limón). En los últimos 20 años había consultado a diferentes profesionales sin encontrar la solución a su problema. Al suspender la ingesta de ácidos por indicación médica presentó disuria y lesiones cutáneas compatibles con rosácea. Por la asociación entre esta patología y la colonización gástrica com H. Pylori se realizó una endoscopia digestiva que confirmó su presencia. Se instituyó tratamiento específico con resolución completa y permanente de los síntomas. Se constató la erradicación a través de una nueva endoscopia digestiva con biopsia. Se sugiere que la conolización gástrica com H. Pylori podría estar relacionada com síntomas irritativos del tracto urinario inferior no aclarados por outra etiología.

prostaglandin synthesis inhibitor: Indomethacin and imipramine in the treatment of primary nocturnal enuresis

In this study, we tried to determine efficacy of indomethacin, a prostaglandin synthesis inhibitor with a tricyclic antidepressant imipramine together in the treatment of primary nocturnal enuresis. This study included 78 patients with primary nocturnal enuresis [PNE] living in the same environmental and social condition. Imipramine [50 mg per night] and indomethacin [25 mg per night] was administered during 8 weeks. At the end of this time, medical therapy was gradually finished and dryness was followed-up. We conclude that indomethacin is a good alternative agent for nocturnal enuresis particularly as a supplementary treatment combined with imipramine, with 78.6% complete response and 74.7% dryness rate

Disúria e freqüência (polaciúria) / Dysury and frequency (polakiuria)

É feita uma síntese da inervaçäo do trato urinário inferior e sua correlaçäo com disúria e frequência, bem como, de forma esquemática as principais causas, diferenciaçäo clínica e manejo do paciente com Disúria e Frequência.

Un caso de neurosis obsesivo-compulsiva con sintomatología de apariencia urológica / A case of compulsive-obsesive neurosis with symptomatology of urological appoarance

Se describe y analiza un caso de neurosis obsesivo-compulsiva que se manifiesta por la compulsión a orinar y el temor a ceder al impulso en público. Se compara este tipo de obsesión relacioanda con la micción con otras descritas en obras de la psiquiatría clásica y se discute su fácil confusión con verdaderas enfermedades orgánicas