Biofeedback therapy for female incontinence due to low urethral resistance.

Urinary incontinence, mostly secondary to low urethral resistance, in 15 women was treated for 6 weeks by biofeedback. A new device equipped with visual and audio signals connected to an intravaginal probe was used by the patient for 15 minutes twice a day. Of the patients 12 were continent subjectively and objectively, 2 had 65 and 75% improvement and could lead a normal life, and only 1 failed to respond and was treated surgically. Besides the quality of the device, success depends largely on the quality of moral support given to the patient during the treatment.

Effect of yohimbine hydrochloride on erectile impotence: a double-blind study.

A double-blind, partial crossover study on the therapeutic effect of yohimbine hydrochloride on erectile dysfunction was done in 82 sexually impotent patients. All patients underwent a multifactorial evaluation, including determination of penile brachial blood pressure index, cavernosography, sacral evoked response, testosterone and prolactin determination, Derogatis sexual dysfunction inventory and daytime arousal test. After 1 month of treatment with a maximum of 42.0 mg. oral yohimbine hydrochloride daily 14 per cent of the patients experienced restoration of full and sustained erections, 20 per cent reported a partial response to the therapy and 65 per cent reported no improvement. Three patients reported a positive placebo effect. Maximum effect takes 2 to 3 weeks to manifest itself. Yohimbine was active in some patients with arterial insufficiency and a unilateral sacral reflex arc lesion, and in 1 with low serum testosterone levels. The 34 per cent response is encouraging, particularly in a Veterans Administration population presenting with a high incidence of diabetes and vascular pathological conditions not found in regular office patients. Only few and benign side effects were recorded, which makes this medication worth an attempt, often as a first line of treatment even at a dose of 8 tablets.

The effect of raveron on the detrusor muscle.

Raveron (a European pharmaceutical consisting of swine prostate extract and m-creosal) was studied in vivo in female mongrel dogs and in vitro bladder studies were conducted on male New Zealand rabbits. Intravenous administration of raveron reduced both the passive and active pressure in dog detrusor in vivo. It did not act in a dose dependent fashion. Chronic treatment with raveron for three to four months caused changes in in rabbits with vesical neck obstruction. An increase in contractility along with a reduced rate of increase in passive force (measurement of bladder stiffness) was observed in relation to obstructed rabbits without treatment. Parallel morphological changes were also observed in this group, consisting of increased muscular hypertrophy, decreased bladder wall thickness and reduced collagen content (readings taken from Masson-Trichrome sections). No influence was observed with bladder specimens from rabbits with six to eight week vesical obstruction or normals that received treatment. In vitro dose response studies showed that a 3.3% dose of raveron significantly reduced passive force in two groups (treated normals and treated rabbits with six to eight week vesical obstruction). Pharmacology studies with potassium chloride and acetylcholine suggest that raveron acts as a calcium antagonist by blocking the influx of extracellular calcium.

A comparison of nocturnal penile tumescence and penile response to erotic stimulation during waking states in comprehensively diagnosed groups of males experiencing erectile difficulties.

The erectile responses of 13 nondysfunctional males and 48 dysfunctional males were compared during Nocturnal Penile Tumescence (NPT) and during exposure to erotic videotapes. The results showed distinct patterns of NPT and daytime responding that could differentiate the various subgroups: those displaying (i) no dysfunction; (ii) vasculogenic erectile dysfunction; (iii) high risk for erectile dysfunction (organic and psychogenic); (iv) psychogenic dysfunction; reactive to erotica; and (v) psychogenic dysfunction; nonreactive to erotica. Subjects participating in this study underwent a comprehensive medical and psychological screening to place them in each subgroup. The penile circumference response to erotic stimuli used in conjunction with NPT response appeared useful in differentiating subgroups of erectile dysfunction and suggested the need for further diagnostic refinement in this area. The majority of vasculogenic dysfunctional subjects experienced greater erection responses during exposure to erotic stimulation than during NPT; several of these subjects achieved almost full erections in waking states but were practically flaccid at night. The discussion covers diagnostic and therapeutic implications.

Cavernosography in conjunction with artificial erection for evaluation of venous leakage in impotent men.

Twenty men with incomplete penile erection or inability to maintain an erection were evaluated to determine if venous leakage was a cause. Cavernosography was performed in conjunction with artificial erection induced by infusion of saline into the corpus cavernosa. Thirteen patients requiring higher than normal rates of saline infusion to achieve or maintain erection showed filling of superficial veins in the flaccid state as well as during erection. In five of the seven patients with normal saline requirements there was no filling of superficial veins, and two showed filling in the flaccid state only. Of the thirteen patients whose conditions were diagnosed as venous leakage, seven underwent surgical ligation of superficial veins and deep penile vein arterialization by a saphenous vein bypass graft between the superficial femoral artery and deep penile vein. All these patients had reduced saline requirements postoperatively. When cavernosography is performed in the flaccid state only, filling of superficial veins can occur normally; therefore, these studies should be performed with artificial erection.

Deep-penile-vein arterialization for arterial and venous impotence.

Eleven impotent men underwent deep-penile-vein arterialization after preoperative assessment by a multidisciplinary team. Penile Doppler pressures, testosterone levels, and nocturnal penile tumescence were used to establish a vasculogenic etiology. Cavernosography, artificial erection by saline infusion, and selective hypogastric arteriography were obtained to delineate whether arterial, venous, or mixed (arterial/venous) factors predominated. Penile revascularization consisted of femoral artery to deep-penile-vein saphenous bypass, with ligation of superficial veins at the base of the penis in patients with venous leakage. Cumulative graft patency was 91% up to 20 months. There were no deaths. The average preoperative flow requirement of values greater than 250 mL/min was reduced to 59 mL/min postoperatively. Follow-up results of nocturnal penile tumescence were excellent in four of four patients with venous (venous leakage), two of three patients with arterial, and one of four patients with mixed factors. Deep-penile-vein arterialization appears to be beneficial for impotence secondary to venous leakage, with inconsistent results for arterial and mixed factors.

Effect of vesical outlet obstruction on detrusor contractility and passive properties in rabbits.

Outlet obstruction was induced in 16 New Zealand rabbits by implanting a polyethylene tube (20 F) for a period of three months. The tube was slit longitudinally and placed around the bladder neck, between the ureters and vasa deferentia. It was left open to induce moderate obstruction and closed by a suture to induce severe obstruction. The animals were studied by cutting consecutive rings from each bladder, which were subjected to the following studies: morphology, contractility and mechanical properties. Morphology. Histology sections of the rings, studied by Hematoxylin and Eosin and Masson-Trichrome stains, demonstrated smooth muscle hypertrophy in moderate obstruction, while hyperplasia was the predominant response in severe obstruction. The average nuclear count per square millimeter of smooth muscle was 251 in controls, 87 in moderate obstruction and 705 in severe obstruction. Bladder wall thickness was significantly increased after both moderate and severe obstruction, as compared to controls. Contractility and mechanical properties. Each ring was tested in a muscle chamber under conditions of maximal electrical stimulation (100 V, 2 ms, 40 Hz). For each ring, full force-length relationships (active and passive) were obtained by stretching the rings in successive increments until length of maximal active force development was reached. Force was normalized per unit cross-sectional area (stress), and length according to a "reference" underformed state (per cent of unloaded length). The maximum active stress of the rings was taken as a measure of bladder contractility, and the rate of increase in passive force as a measure of detrusor stiffness. In all groups, the body of the detrusor exerted better contractility, as compared to a rigid, less contractile base. In the obstructed groups, detrusor contractility was significantly decreased at the body level, with increased stiffness, as compared to controls. The length at which maximum contractility was exerted, however, increased in moderate obstruction, and decreased in severe obstruction.

Pathologic involvement of the urinary bladder in progressive systemic sclerosis.

We describe 2 patients with progressive systemic sclerosis (PSS) who manifested characteristic pathologic abnormalities in the urinary bladder. Increased connective tissue deposition in the lamina propria and between smooth muscle bundles was demonstrated in both patients and endovascular proliferation in small arteries of the bladder was noted in one patient. Both patients had persistent unexplained microscopic hematuria; one patient manifested urinary frequency and incontinence. The relationship of these clinical abnormalities to the pathologic findings in the bladder is unclear. Structural or functional abnormalities of the urinary bladder may develop in patients with PSS.

Rapid cystometry and sacral-evoked response in the diagnosis of peripheral bladder and sphincter denervation.

Rapid cystometry and sacral-evoked responses were used in 25 patients presenting with peripheral nerve lesions affecting the bladder. Type A contractions were found on rapid cystometry in 87 per cent of the patients, while these waves were only occasional and inconsistent in 79 controls. The efficiency of this test to demonstrate sacral denervation was 88 per cent. Sacral-evoked response showed an increased latency or absence of response in 95 per cent of the patients. These tests are proposed as useful clinical tools for the diagnosis of a peripheral sacral nerve lesion.

A new catheter to measure urethral compliance in females: normal values.

We describe a new probe made of several F5 Vinyl tubes glued and staggered together in such a way that the catheter progressively increases in size (from F5 to F30), as more tubes are joined. At each size, pressure is recorded through a single side hole in one of the tubes. Pressure within the urethra is thus successively recorded from F5 to F30 as the catheter is further introduced. A single pressure transducer is used since the lines of the probe are separately and successively connected to the transducer through a 6-channel manifold, as one proceeds to the next diameter. Pressure diameter curves are obtained and reported on a graph. The data are analyzed by fitting the graphs with a one exponential equation P = PoeaD; 2 parameters are computed: Po, the initial pressure when the urethra is catheter free, and a, the rate of exponential increase in pressure as higher diameters are introduced to measure urethral wall stiffness. This catheter was used to measure the maximum urethral pressure in 10 young nulliparous volunteers, at each level of stretch. The values of Po and a were found to be respectively 74.4 +/- 7.7 cm. H2O and 0.08 +/- 0.02. The quantitative measurement of urethral compliance constitutes for us an integral part in the urodynamics assessment of female patients presenting with lower urinary tract dysfunction.

Abnormal urethral compliance in females diagnosis, results and treatment. Preliminary study.

We measured urethral compliance in 57 patients using a catheter of increasing diameter. The measurement makes it possible to differentiate clearly between rigidity and hyperlaxity of the female urethra. In both instances, the initial pressure (Po) is lower than normal, but the rate of pressure increase (a), with larger catheter sizes, is significantly higher in cases of urethral rigidity and on the contrary parallel to normal in cases of hyperlaxity. This distinction allows for more accuracy in the determination of therapeutic indication. An inversely proportional correlation was found between the initial urethral pressure and the rate of pressure increase (r = 0.74). The initial pressure is generally lower in older women (r = 0.56).

Effect of diethylstilbestrol on bladder contractility in male rats.

The effect of diethylstilbestrol (DES) on bladder contractility was studied in vitro in 8 rats while 5 untreated animals were used as normal controls. Of the treated animals, 4 received 0.05 mg./day of DES during 8 weeks while another 4 were treated for 14 weeks with the same dose. We studied the animals by cutting consecutive rings from each bladder and testing them in a muscle chamber, under conditions of maximal electrical stimulation which had been previously determined in 3 animals. Parameters that produced maximal contractions were: 100 V, 40 Hz, and 2 msec. For each ring, we obtained full force-length relationships by stretching the rings in successive increments until length of maximal active force development was reached. For each bladder, alternate rings were tested in the muscle chambers while the remaining rings were used to determine collagen percentage with Woessner assay. In all animals, the ring with the largest diameter which was obtained from the widest portion of the bladder gave the highest contraction. The maximal active force of this ring was taken as a measure of contractility of the bladder. For controls, the maximal active force was 7.30 +/- 0.3 g. After 8 weeks of DES treatment, it decreased to 5.9 +/- 0.79 g and after 14 weeks, it further decreased to 2.15 +/- 0.99 g. The reduction in active force from controls after 8 and 14 weeks were statistically significant. Passive force and collagen content, however, did not change after either 8 or 14 weeks. In conclusion, these data show that DES decreases bladder contractility in male rats without affecting passive forces and muscle-collagen ratio.

The elastic behavior of the urinary bladder for large deformations.

The purpose of this paper is to investigate the theoretical basis for the pressure-distension behavior of the urinary bladder. A finite strain theory is developed for hollow spherical structures and it is shown that the Treloar model is a good prototype only for rubber balloons. The pressure-extension ratio relationship is inverted to lead a general form of strain energy function, and fitted by an empirical relation involving one exponential. The following form of strain energy function is derived: W(lambda, lambda, lambda -2) = C1 (P(1), a) + P(1)C2 (a, lambda)ea(lambda -1). Where C1(P(1), a) is a constant (N m-2), P(1) is the initial pressure, a is the rate of pressure increase and C2 (a, lambda) a third degree polynomial relation. P(1) and a are experimentally determined through volumetric pressure-distension data. It is verified that this type of energy function is also valid for uniaxial loading experiments by testing strips coming from the same bladder for which P(1) and a were computed. There is a good agreement between the experimental points and the theoretical stress-strain relation. Finally, the strain energy function is plotted as a function of the first strain invariant and appears to be of an exponential nature.

Early detection of neurogenic bladder dysfunction caused by protruded lumbar disk.

A case of cauda equina compression was suspected from urinary symptoms. The diagnosis was based on the presence of type A contraction on rapid cystometry and prolonged latency of the sacral evoked response. Such findings pointed to the need for myelography. Lumbar laminectomy, with removal of a ruptured intervertebral disk and cauda equina decompression, resulted in return of normal urination and normal cystometry and electromyogram of the perineal muscles.

The stop-flow technique: a way to measure detrusor strength.

Maximum intravesical isometric pressure, obtained by stopping the urinary flow in progress, measures detrusor strength and allows an accurate evaluation of bladder contraction. Micturition studies were performed on 7 normal subjects and 48 patients with urinary obstruction, enuresis, neurogenic vesical dysfunction or stress incontinence. In the case of obstruction maximum isometric pressure appears to relate to the degree of detrusor compensation and allows a prognosis as to the future of detrusor function after the obstruction is removed. An unexpected large proportion of patients with enuresis were found to have high maximum isometric pressure usually associated with elevated urethral resistance, suggesting that urinary obstruction may not uncommon as an etiological factor of enuresis.

Viscoelastic properties of bladder strips: standardization of a technique.

The standardization of a stretching technique for bladder strips was carried out as a step towards its clinical use. Six variables were studied on specimens of prefrozen bladders taken from human cadavers. Repeated elongations change the nature of the muscle. Viscoelastic coefficients of mucosa are markedly higher than those of muscle. It is necessary to study specimens that have essentially the same direction of fibers and that are located in the same portion of the bladder. The thickness of the specimen does not affect coefficients significantly. The percentage of muscular elongation, in relationship to specimen length, should not exceed 20 per cent in order to have linear reproducible results.

Dynamics of obstruction in acontractile bladder: attempt at management.

Five patients with acontractile bladders were observed during lateral voiding cystourethrography in the resting and straining states. Two abnormalities were noted: (1) posterior displacement of the bladder with closure of the posterior vesicourethral angle on straining, and (2) plication of the bladder over the symphysis pubis, resulting in the formation of an anterior pseudodiverticulum. Two other abnormalities are discussed: closure of the anterior vesicourethral angle, and descent of the bladder and prostate in flaccid paraplegia, causing plication at the prostatic apex. Surgical techniques for the correction of the abnormalities are described.

Collagen in 155 human bladders.

The percentage of bladder collagen, as obtained by the dosage of hydroxyproline, was determined in autopsy specimens from 48 female and 107 male cadavers. The average percentage of collagen in the human bladder is 57.4 per cent (+/- 9) of the dry weight of insoluble protein. There is good correlation (r = 0.55) between detrusor and trigone collagen content. There is no significant difference between pre- and postpuberty age groups in relative collagen content. In females more than 50 years of age there is a significant increase in collagen.