BoNT/A in the Urinary Bladder—More to the Story Than Silencing of Cholinergic Nerves

Botulinum neurotoxin (BoNT/A) is an FDA and NICE approved second-line treatment for overactive bladder (OAB) in patients either not responsive or intolerant to anti-cholinergic drugs. BoNT/A acts to weaken muscle contraction by blocking release of the neurotransmitter acetyl choline (ACh) at neuromuscular junctions. However, this biological activity does not easily explain all the observed effects in clinical and non-clinical studies. There are also conflicting reports of expression of the BoNT/A protein receptor, SV2, and intracellular target protein, SNAP-25, in the urothelium and bladder. This review presents the current evidence of BoNT/A’s effect on bladder sensation, potential mechanisms by which it might exert these effects and discusses recent advances in understanding the action of BoNT in bladder tissue.

Therapeutic outcome of active management in male patients with detrusor underactivity based on clinical diagnosis and videourodynamic classification

Detrusor underactivity (DU) could be resulted from many different etiologies. Patients with DU might have reduced bladder sensation, low detrusor contractility, and large post-void residual volume. This study analyzed therapeutic outcome of active management for male DU patients, based on clinical and urodynamic characteristics. Male DU patients aged > 18 years old were retrospectively reviewed from the videourodynamic study (VUDS) records in recent 10 years. The patients’ demographics, VUDS results, treatment modalities, and treatment outcome were analyzed. The treatment outcomes were compared among patients with different DU subgroups, clinical diagnosis and treatment modalities. Patients with voiding efficiency of > 66.7% were considered having a successful treatment outcome. For comparison, 30 men with normal VUDS finding served as the control arm. Most of the DU patients had reduced bladder sensation. The reduced bladder sensation is closely associated with low detrusor contractility. After active treatment, a successful outcome was achieved in 68.4% of patients after bladder outlet surgery, 59.1% after urethral botulinum toxin A injection, and 57.6% after medical treatment, but only 18.2% after conservative treatment. A successful treatment outcome was achieved in patients with an intact detrusor contractility, either low (69.2%) or normal voiding pressure (81.8%), and in patients with a normal or increased bladder sensation (78.1%). However, patients with detrusor acontractile (41.3%) or absent bladder sensation (17.9%) had less favorable treatment outcome after any kind of urological management. This study revealed that active management can effectively improve voiding efficiency in patients with DU. The normal bladder sensation, presence of adequate detrusor contractility, and bladder outlet narrowing during VUDS provide effective treatment strategy for DU patients. Among all management, BOO surgery provides the best treatment outcome.

Urinary symptoms and urodynamic findings before and after vaginal surgery for pelvic organ prolapse

To ascertain the difference in urodynamic findings, specifically bladder sensation, and urinary symptoms after vaginal surgery for Pelvic Organ Prolapse (POP). Retrospective data analysis of 126 women who underwent vaginal surgery for POP without simultaneous anti-incontinence procedure from January 2013 to April 2019 at Siriraj Hospital, Thailand. Baseline characteristics, intraoperative details and pre and post-operative urinary symptoms and urodynamic findings were recorded. There was no significant difference in the pre and post-operative first desire to void, at 158±53 mL and 162±64 mL, respectively (p=0.518). Incidence of increased bladder sensation was also unchanged, from 46.0% to 46.8% (p=1.00). Post-operative urodynamic stress incontinence was significantly increased, from 15.9% to 31.0% (p=0.003), as was the incidence of weak bladder contractility index (<100), from 47.3% to 61.8% (p=0.005). Significant improvements in post-operative urge urinary incontinence, urgency and voiding dysfunction were noted, from 50.8% to 31.7% (p=0.001), 63.5% to 38.9% (p<0.001) and 42.9% to 5.6% (p<0.001), respectively. No significant difference in bladder sensation after vaginal surgery for POP repair was noted. However, urinary symptoms significantly improved after surgery.

The role of the urotherapist in the care of patients with pelvic floor disorders

Background: To improve the management of healthcare requirements of pelvic floor disorders (PFDs) in adult patients, interprofessional collaborations are emerging. The aim of this study is to describe and evaluate the activities of a urotherapist in adult patients with PFDs. Methods: The prospective observational study was carried out at the Department of ObGyn at the Cantonal Hospital Winterthur/Switzerland, from July 2016 to June 2018. The activities of the urotherapist were assessed with respect to parameters such as, number of consultations, type of counselling, time frame of consultations and therapy as well patient satisfaction. Demographic and clinical data were collected by self-administered questionnaires and electronic medical data systems. Results: 1709 patients were examined by urogynecologists. Of these patients, 514 (30%) were subsequently referred to a urotherapist. 58% of the 514 patients were over 65 years old. The most common PFDs were complaints about increased bladder sensation such as an overactive bladder, recurrent urinary tract infections, chronic cystitis and pelvic pain syndrome in 221 patients (43%); the second most common was pelvic organ prolapse in 151 patients (29%). The average number of urotherapist consultations per patient was 3 . In the group with >5 consultations, 59% were patients with increased bladder sensation. The most common type of consultation was phone counselling (59% of all activities). Conclusions: Increased bladder sensation related complaints are chronic problems that result in the highest numbers of urotherapist consultations. Interprofessional collaborations between urotherapist, as a specialist nurse, and urogynecologist should be implemented in urogynecological units and further developed in the future.

Urodynamic Assessment of Neuronal Intranuclear Inclusion Disease

Neuronal intranuclear inclusion disease (NIID) is a disease that causes leukoencephalopathy (dementia) and peripheral neuropathy (variable manifestation including bladder dysfunction). This is the first urodynamic report to show that bladder dysfunction in NIID is a combination of detrusor overactivity, decreased bladder sensation, large post-void residual, and neurogenic changes in the sphincter electromyogram. This report will help managing bladder dysfunction in NIID.