Cognitive challenges in persons with spina bifida: Bearing on urological dysfunctions?

AIM: To evaluate if adult persons with spina bifida (SB) who have urinary tract complications have cognitive difficulties that can be identified by neuropsychological tests. METHODS: All individuals with SB ≥ 18 years of age registered at a regional outpatient clinic (n = 219) were invited, of which, 154 persons were included. Neuropsychological assessment of their cognitive status was performed with Wechsler Adult Intelligence Scale®-Fourth Edition: Coding, Block design, Arithmetic's, FAS (word generation), Rey Auditory Verbal Test for learning, and delayed recall 30 min. Bladder and bowel function were assessed with questions used by the Nordic Spinal Cord Injury Registry (NSCIR) in structured interviews, by questionnaires, and by chart reviews. RESULTS: Average neuropsychological test results for this SB population was shown to be approximately 1 SD under the median for the general population. The Coding test showed significantly lower test results as compared with the whole SB group in persons with urinary tract complications, especially urinary tract infections, reduced kidney function, dependent emptying of the bladder, and the bowel and accidental bowel leakage. The Arithmetic's test showed a significant difference between subgroups in all parameters except reduced kidney function whereas the other neuropsychological tests were significantly correlated with some but not all urological parameters. CONCLUSION: We propose neuropsychological testing with primarily two tests to find those persons with SB who, due to cognitive challenges, might need extra support to minimize urological complications.

Voiding conditions, renal and bowel function in a cohort of adults with spina bifida.

AIM: To map voiding patterns, degree of continence, use of drugs for voiding disorders, kidney function and surgical interventions but also the bowel function in a near-total regional cohort of adults with spina bifida aged more than or equal to 18 years. METHODS: All individuals more than or equal to 18 years of age with spina bifida registered at a regional outpatient clinic (n = 219) were invited to participate, of which 196 persons were included. Bladder and bowel function were assessed according to questions used by the Nordic Spinal Cord Injury Registry by structured interviews and questionnaires in combination with review of patient charts including kidney function. RESULTS: Twenty percent of the patients voided spontaneously. Fifty-four percent used clean intermittent catherization (CIC) and of these, 14% had also undergone augmentation of the bladder and/or implantation of an artificial sphincter or sling, 23% had undergone major urological surgery, and 3% had an indwelling catheter. Seventeen percent of patients voiding spontaneously or using CIC reported total continence but as many as 36% reported daily leakage. Anticholinergics was the most common drug, used by 21% in the total cohort. About 13% of the patients had a reduced kidney function but only 1.5% had end stage renal failure. Seventy-three percent had problems emptying the bowel and 18% experienced fecal leakage weekly or even daily. CONCLUSION: We found a large variation in problems with bladder and bowel function in this adult group of persons with spina bifida. A structured customized program for follow-up seems necessary to optimize their health status in these areas.

Nitric oxide as a marker for evaluation of treatment effect of cyclosporine A in patients with bladder pain syndrome/interstitial cystitis type 3C.

OBJECTIVE: Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic inflammatory disease and to date few treatments or tools for investigating the activity of the disease are available. This study evaluated whether luminal nitric oxide (NO) could be used as a marker for evaluation of therapeutic outcome in BPS/IC type 3C treated with the immunosuppressive agent cyclosporine A (CsA). MATERIAL AND METHODS: Ten patients with BPS/IC type 3C were given CsA for 16 weeks, initially at 3 mg/kg/day, and after 12 weeks the dose was scaled down. Formation of NO was measured in the urinary bladder with a silicone catheter, and symptom and bother score related to the disease were evaluated with the Interstitial Cystitis Symptom and Problem Index, every second week. RESULTS: All patients had elevated NO levels in the bladder initially and NO levels decreased during treatment with CsA. When the dose of CsA was lowered NO formation increased and after 2 weeks without medication, the NO formation was the same as before the study began. CONCLUSIONS: The results indicate that measurement of NO is a tool for evaluating the response to anti-inflammatory treatment in patients with BPS/IC type 3C. NO could serve as a marker for assessing the activity of the inflammation.

Localization and expression of inducible nitric oxide synthase in patients after BCG treatment for bladder cancer.

Treatment with Bacillus Calmette Guerin (BCG) bladder instillations is an established treatment modality for superficial urinary bladder cancer and carcinoma in situ (CIS), but the anti-tumor mechanisms following BCG instillations remain largely unknown. Previous data show increased nitric oxide (NO) concentrations in the urinary bladder from patients treated with BCG suggesting that NO-formation may be involved in the BCG mediated effect. In the present study we evaluated 11 patients with urinary bladder cancer who had received BCG treatment and 11 tumor free control subjects. We performed immunohistochemistry, Western blot and real-time polymerase chain reaction (PCR) on bladder biopsies to establish inducible nitric oxide synthase (iNOS) protein levels and localization as well as iNOS mRNA expression. Endogenous NO formation in the bladder was also measured. In patients with bladder cancer who had received BCG treatment iNOS-like immunoreactivity was found in the urothelial cells but also in macrophages in the submucosa. Furthermore, endogenously formed NO was significantly increased (p<0.001) in the BCG treated patients and they had a ten-fold increase in mRNA expression for iNOS compared to healthy controls (p=0.003). In conclusion iNOS was found to be localized to the urothelium and macrophages underlying it. Our study also confirms elevated levels of endogenously formed NO and increased mRNA expression and protein levels for iNOS in patients with BCG treated bladder cancer. These data further support the notion that NO may be involved in the anti-tumor mechanism that BCG exerts on bladder cancer cells.

Measurement of luminal nitric oxide in the uterine cavity using a silicon balloon catheter.

The aim of this pilot case-control study was to measure nitric oxide (NO) gas in air incubated in a catheter balloon in the uterus of healthy women and patients with pelvic inflammatory disease, to determine the optimal time of incubation and to find whether NO level rises after manipulation in the uterine cavity. We measured nitric oxide levels in air incubated for 2-10 min in a catheter balloon in the uterine cavity in 6 non pregnant women from 22 to 50 years of age with lower abdominal pain and 10 healthy women with regular menstrual cycles. After an incubation time of just 2 min, intrauterine nitric oxide levels were significantly increased in patients with diagnosed pelvic inflammatory disease compared to healthy women. Uterine nitric oxide levels did not rise after manipulation in the uterine cavity. In conclusion, NO gas can be measured directly in the uterine cavity with a fast, simple, well-tolerated and safe method. The levels of nitric oxide are increased in women diagnosed with pelvic inflammatory disease already after an incubation time of 2 min.

Characteristics of biofilms from urinary tract catheters and presence of biofilm-related components in Escherichia coli.

Long term catheterization of the urinary tract leads to bacterial colonization of the urine, whereby adherence to the catheter surface is a major determinative factor for colonization. Collection of bacterial isolates from urine and urinary catheters of 45 patients showed multi-species catheter-colonization, while Escherichia coli isolates were frequently found in the urine in high numbers. Biofilm formation of catheter and urine-derived E. coli isolates was associated with the presence of the fluA gene, loss of O-antigen, and expression of type 1 fimbriae. The second messenger cyclic di-GMP (cdiGMP), a major regulator of biofilm formation, regulated adherence to the catheter surface in a selected clinical isolate suggesting that the cdiGMP second messenger pathway may be a target for anti-biofilm therapeutic approaches.

Measurement of nitric oxide in the vagina.

OBJECTIVE: Local measurement of nitric oxide (NO) gas has been used to detect and monitor inflammatory processes in the airways, the colon and in the urinary bladder, but so far NO has not been studied in the lower female genital tract. The objective of this study is to measure NO gas directly in the vaginal lumen of healthy women and in patients with vaginitis. SETTING: The outpatient clinic of a university hospital. METHODS: Eighteen non-pregnant women from 19 to 65 years of age with symptoms of vaginitis, eight healthy women in reproductive age with regular menstrual cycles and nine healthy postmenopausal women were enrolled in the study. NO levels were measured in air incubated for five minutes in a catheter balloon in the vagina. RESULTS: In patients with symptoms of vaginitis, NO concentration was almost 100-fold increased compared to healthy controls (p<0.001) with no individual overlap. Vaginal NO levels were uniformly low among healthy women, both in reproductive age and in menopause. CONCLUSIONS: NO gas can be measured directly in the vagina with a fast, simple and safe method. The levels of NO are increased in patients with vaginitis.

Intrauterine nitric oxide in pelvic inflammatory disease.

OBJECTIVE: To measure nitric oxide gas directly in the uterus of healthy women and patients with suspected pelvic inflammatory disease. DESIGN: Pilot case-control study. SETTING: The emergency department of a university hospital. PATIENT(S): Twenty premenopausal, nonpregnant women from 18 to 48 years of age with lower abdominal pain and nine healthy women with regular menstrual cycles were included. INTERVENTION(S): We measured nitric oxide levels in air incubated for 5 minutes in a catheter balloon in the uterine cavity. MAIN OUTCOME MEASURE(S): Intrauterine nitric oxide concentration in controls and patients. RESULT(S): In patients with lower abdominal pain, nitric oxide was almost 100-fold increased in those in whom pelvic inflammatory disease had been diagnosed compared with those in whom appendicitis had been diagnosed with no individual overlap. Uterine nitric oxide levels were uniformly low in healthy women throughout the menstrual cycle, compared with those with pelvic inflammatory disease. CONCLUSION(S): Nitric oxide gas can be measured directly in the uterine cavity with a fast, simple, and safe method. The levels of nitric oxide are increased in patients with pelvic inflammatory disease.

Efficacy and impact of botulinum toxin A on quality of life in patients with neurogenic detrusor overactivity: a randomised, placebo-controlled, double-blind study.

OBJECTIVE: To evaluate the effect of a single injection of 500 U of botulinum toxin A (BTX-A; Dysport) on use of oral rescue medication, bladder compliance, continence and quality of life in a randomized, placebo-controlled, double-blind study in patients with incontinence due to neurogenic detrusor overactivity. As this group of patients often have severe symptoms, oral tolterodine was allowed as rescue medication and the amount of tolterodine consumed was our primary endpoint. MATERIAL AND METHODS: A total of 31 patients with urinary leakage due to spinal cord injury, myelomeningocele, trauma at birth, multiple sclerosis and myelitis of another cause were randomized to intravesical injections of either 500 U of BTX-A or placebo. Intake of tolterodine and episodes of urinary leakage were registered. Cystometry was performed after 6, 12 and 26 weeks and quality of life was assessed. RESULTS: Patients in the BTX-A group had a significantly lower intake of tolterodine throughout the study compared to those in the placebo group (p=0.003). Cystometric capacity was significantly higher at 6 (p<0.001) and 12 weeks (p=0.026) and maximum detrusor pressure and frequency of urinary leakage were significantly (p<0.01) lower during follow-up in the BTX-A group compared to the placebo group. In addition, many quality-of-life parameters were significantly improved in the BTX-A group compared to the placebo group. CONCLUSIONS: Intravesical injection of 500 U of BTX-A in patients with neurogenic detrusor instability was shown to be an effective treatment which reduced use of oral medication, high detrusor pressure and frequency of urinary leakage during the overall study period of 26 weeks. Quality of life was also significantly improved.

The antimicrobial peptide cathelicidin protects the urinary tract against invasive bacterial infection.

The urinary tract functions in close proximity to the outside environment, yet must remain free of microbial colonization to avoid disease. The mechanisms for establishing an antimicrobial barrier in this area are not completely understood. Here, we describe the production and function of the cathelicidin antimicrobial peptides LL-37, its precursor hCAP-18 and its ortholog CRAMP in epithelial cells of human and mouse urinary tract, respectively. Bacterial contact with epithelial cells resulted in rapid production and secretion of the respective peptides, and in humans LL-37/hCAP-18 was released into urine. Epithelium-derived cathelicidin substantially contributed to the protection of the urinary tract against infection, as shown using CRAMP-deficient and neutrophil-depleted mice. In addition, clinical E. coli strains that were more resistant to LL-37 caused more severe urinary tract infections than did susceptible strains. Thus, cathelicidin seems to be a key factor in mucosal immunity of the urinary tract.

Measurement of nitric oxide may differentiate between inflammatory and non-inflammatory prostatitis.

OBJECTIVE: The majority of patients with prostatitis have chronic non-bacterial prostatitis/chronic pelvic pain syndrome of inflammatory type (Category IIIA) or non-inflammatory type (Category IIIB), based on the National Institutes of Health classification. The aim of this study was to investigate whether measurement of nitric oxide (NO) formation in the prostatic urethra can be used as a marker for inflammation in the evaluation of patients with chronic prostatitis/pelvic pain syndrome. MATERIAL AND METHODS: A total of 25 men with prostatitis were examined. In 8 patients >10 white blood cells/high-power field (WBC/hpf) were found in expressed prostatic secretion (EPS) (Category IIIA), whereas the other 17 had no signs of inflammation (Category IIIB). NO production was measured using a silicon catheter, with the catheter balloon being placed in the prostatic urethra. Room air (5 ml) was incubated for 5 min and analyzed. NO formation in the urinary bladder was also measured. RESULTS: The NO concentration in the prostatic urethra was significantly higher in the 8 patients with >10 WBC/hpf than in those with <10 WBC/hpf. The NO concentration in the urinary bladder was low in both groups. CONCLUSIONS: We found an elevated NO concentration in the prostatic urethra in patients with >10 WBC/hpf in the EPS but not in those with <10 WBC/hpf, which supports the theory of different pathogeneses for Categories IIIA and IIIB. Measurement of NO production in the prostatic urethra can be used to discriminate between the two categories and as the method is easy and fast it may represent an attractive alternative to the four-glass test.

Enhanced formation of nitric oxide in bladder carcinoma in situ and in BCG treated bladder cancer.

The purpose of the study was to analyze endogenous nitric oxide (NO) formation and NO-synthase (NOS) gene expression in the urinary bladder from patients with urinary bladder cancer and to investigate the relationship between local NO formation, treatment with Bacillus Calmette Guerin (BCG) and clinical stage in bladder cancer patients. One hundred and three patients with bladder cancer were studied. Endogenous formation of NO was measured in 72 patients, including 6 patients with BCG treated bladder cancer and 6 tumor free control subjects. iNOS expression was analyzed at transcriptional and protein level in biopsies from 31 patients with bladder cancer by real time polymerase chain reaction (PCR) and Western blot (WB), respectively. Three patients in this group had received BCG treatment. Eight biopsies from normal bladder served as control for PCR and WB analysis. Patients with carcinoma in situ (CIS) had higher iNOS expression (p<0.01) and NO formation (p<0.01) than control subjects and patients with papillary tumors without concomitant CIS. Markedly increased iNOS expression (p<0.05) and NO formation (p<0.001) were also found in patients treated with BCG as compared to the other groups. In conclusion, the presence of elevated NO concentration and iNOS expression in the urinary bladder from BCG treated patients and patients with CIS further supports the notion that NO may be an important factor in bladder cancer biology and that the BCG effect on superficial bladder cancer may partly be due to stimulation of local NO formation.

Nitric oxide as an objective marker for evaluation of treatment response in patients with classic interstitial cystitis.

UNLABELLED: Nitric oxide (NO) has previously been shown to be a marker for inflammatory disorders in the bladder. We investigated if the measurement of NO can be used to evaluate the treatment response in classic interstitial cystitis (IC). MATERIALS AND METHODS: A total of 15 patients diagnosed with classic IC were included. The patients were treated with oral prednisolone for 8 weeks. We evaluated patient symptoms/problems with the IC index, and we measured NO formation in the bladder. RESULTS: Seven patients were classified as responders with a 4 point or more decrease in symptom score after 8 weeks of treatment. In this group the mean symptom score was +/- SEM decreased from 15 +/- 1 to 7 +/- 2 at the end of therapy (p <0.05). The problem score was also significantly reduced. Responders showed a clear decrease in bladder NO. The 8 nonresponders did not show any improvement in symptom/problem score and there was no change in bladder NO during steroid treatment. Furthermore, the study showed a statistically significant correlation between changes in symptom/problem score and changes in luminal bladder NO in each patient. CONCLUSIONS: The study shows that NO can be used not only to measure inflammation in patients with IC, but also to evaluate objectively the treatment response in individuals. This makes NO formation a useful marker in the assessment of classic interstitial cystitis.

Nitric oxide as putative second messenger in nerve-induced cervical gland secretion in the guinea-pig.

Uterine cervical secretory cells receive a sympathetic cholinergic secretomotor innervation. It has been suggested that glandular nitric oxide (NO) production is a prerequisite for muscarinic-induced carbohydrate secretion in the endometrium and the seminal vesicle. A similar pattern for nerve-induced carbohydrate secretion in the cervix could be assumed. Nitric oxide synthase (NOS) activity was evaluated via formation of L-citrulline from L-arginine. The NADPH-diaphorase nitroblue technique was used for histochemical investigation. The cervix with the adjacent hypogastric nerve was placed in an isolated organ bath and the secretion was evaluated as an amount of carbohydrate. A calcium-dependent formation of citrulline was found in the cervix indicating NO formation. Strong NADPH-staining cells were found in the glandular ducts and in the glandular linings of the cervix. Stimulation of the hypogastric nerve induced carbohydrate secretion, which was inhibited by N-nitro-L-arginine methyl ester (L-NAME). D-NAME did not affect the secretory response. Carbachol and the NO donor glyceryl trinitrate (GTN) induced carbohydrate secretion in the cervical glands. No synergistic effect was noted probably due to an all-or-none type of secretion. N-nitro-L-arginine (L-NNA) and L-NAME inhibited carbachol-induced secretion. The results suggest that glandular NO production is a prerequisite for the autonomic nervous modulation of cervical secretion in the guinea-pig. This could have implications regarding fertility and fecundity.

ERK1/2 mediates insulin stimulation of Na(+),K(+)-ATPase by phosphorylation of the alpha-subunit in human skeletal muscle cells.

Insulin stimulates Na(+),K(+)-ATPase activity and induces translocation of Na(+),K(+)-ATPase molecules to the plasma membrane in skeletal muscle. We determined the molecular mechanism by which insulin regulates Na(+),K(+)-ATPase in differentiated primary human skeletal muscle cells (HSMCs). Insulin action on Na(+),K(+)-ATPase was dependent on ERK1/2 in HSMCs. Sequence analysis of Na(+),K(+)-ATPase alpha-subunits revealed several potential ERK phosphorylation sites. Insulin increased ouabain-sensitive (86)Rb(+) uptake and [(3)H]ouabain binding in intact cells. Insulin also increased phosphorylation and plasma membrane content of the Na(+),K(+)-ATPase alpha(1)- and alpha(2)-subunits. Insulin-stimulated Na(+),K(+)-ATPase activation, phosphorylation, and translocation of alpha-subunits to the plasma membrane were abolished by 20 microm PD98059, which is an inhibitor of MEK1/2, an upstream kinase of ERK1/2. Furthermore, inhibitors of phosphatidylinositol 3-kinase (100 nm wortmannin) and protein kinase C (10 microm GF109203X) had similar effects. Notably, insulin-stimulated ERK1/2 phosphorylation was abolished by wortmannin and GF109203X in HSMCs. Insulin also stimulated phosphorylation of alpha(1)- and alpha(2)-subunits on Thr-Pro amino acid motifs, which form specific ERK substrates. Furthermore, recombinant ERK1 and -2 kinases were able to phosphorylate alpha-subunit of purified human Na(+),K(+)-ATPase in vitro. In conclusion, insulin stimulates Na(+),K(+)-ATPase activity and translocation to plasma membrane in HSMCs via phosphorylation of the alpha-subunits by ERK1/2 mitogen-activated protein kinase.

Intravesical nitric oxide production discriminates between classic and nonulcer interstitial cystitis.

PURPOSE: Interstitial cystitis (IC) is one of the most bothersome conditions in urological practice. There are 2 subtypes, classic and nonulcer IC, with similar symptoms but different outcomes with respect to clinical course and response to treatment. Histologically there are fundamental differences between the 2 subtypes, classic IC presenting a severe abnormality of the urothelium and characteristic inflammatory cell infiltrates while inflammation is scant in nonulcer IC. Regulation of urinary nitric oxide synthase activity has been proposed to be of importance for immunological responses in IC. We present evidence of a profound difference between the 2 subtypes concerning nitric oxide production, mirroring the differences in inflammatory response in IC. MATERIALS AND METHODS: A total of 17 patients with both subtypes and active disease as well as patients with disease in remission were included in the study, all diagnosed according to National Institute for Diabetes and Digestive and Kidney Diseases criteria. Luminal nitric oxide was measured in the bladder of patients using a chemiluminescence nitric oxide analyzer. RESULTS: All patients with classic IC had high levels of NO. None of the other patients had any significant increase in NO levels in the bladder. The NO level in patients with classic IC was not related to symptoms but rather to the assignment to this specific subgroup of IC. The highest levels of NO were found in patients in the initial phase of classic IC. CONCLUSIONS: The difference in NO evaporation between classic and nonulcer IC allows for subtyping of cases meeting National Institute for Diabetes and Digestive and Kidney Diseases criteria without performing cystoscopy. The findings in the present series together with previous findings clearly demonstrate that the 2 subtypes of IC represent separate entities. This separation further emphasizes the need to subtype all cases included in all scientific matters, ensuring that the 2 subtypes are evaluated separately in clinical studies.