과민성 방광의 최신지견

이유식(Yoo-Sik, Lee) 대한임상노인의학회 2002 대한임상노인의학회지 Vol.3 No.3

The overactive bladder is defined by the international Continence Society as a disorder of filling/storage in which involuntary bladder contraction are demonstrated while the patient is attempting to inhibit. If the involuntary bladder contraction are secondary to a known neurologic disease, the condition is known as detrusor hyperreflexia, If the involuntary bladder contraction are not due to a known neurologic disease, then the condition is known as detrusor instability. The symptom of the overactive bladder consist of urgency and/or frequency and/or nocturia and/or urge incontinence. These may exit singly or combination with one another. The overactive bladder can be manifested by any one or a combination or these symptoms. Treatment modalities of overactive blader will involve intervention along the whole route of the micturition reflex, and different modalities will be combined. Although it is well known that estrogen and progesterone receptors are present in the vagina, lower urinary tract and pelvic floor, and that symptomatic, cytologic, and urodynamic changes in the lower urinary tract had been demonstrated during the menstrual cycle, and following menopause, there have been few controlled studied of estrogen therapy on the overactive bladder. Peripheral targets for the drug treatment of the overactive bladder may be in the bladder, urethra, prostate or peripheral nerve. Antomuscarinic drugs are still the most widely used agents for the treatment of the bladder overactivity. Currently used drug, however, lack of sensitivity for the bladder, and this limits their usefulness. Currently, the muscarinic receptors remain a main target for drug used to treat the overactive bladder. However, the complexity of muscarinic receptor functions in the bladder and elsewhere in the body makes it difficult to predict the optimal profile of subtype selectivity for the treatment of bladder overactivity. Since M3 receptors are located not only in the bladder but also in the salivary glands and the intestine, the concept of selected M3 receptor antagonism may not offer a therapeutic advantage, since two of the most common side effects, dry mouth and constipation, would not be avoid. If the subtypes of receptors which mediate bladder contractions and those which produce the main side effects of the anti-muscarinic agents were entirely known, more effective agents with fewer side effects for the treatment of bladder overactivity might be obtainable. Pharmacologic treatment will be directed not only at function but at structure, and the concept of uroselectivity will assume greater importance.

The Role of Intra-abdominal Pressure Measurement in Awake Rat Cystometry

이택,윤상민 대한배뇨장애요실금학회 2013 International Neurourology Journal Vol.17 No.2

Rat cystometry is increasingly being used in research on overactive bladder and is a research tool for investigating bladder functions during the storage and voiding phases. Measurement of the pressure in the bladder is an essential part of cystometry, although that pressure is the sum of both detrusor and intra-abdominal pressures. In anesthetic cystometry, measurement of the intra-abdominal pressure is not necessary, because the values of this variable are negligible. In awake cystometry, however, it is mandatory to separate the changes in intra-abdominal pressure from those in intravesical pressure, because consciousness causes much variability in intra-abdominal pressure. This review describes why we use the term “detrusor overactivity” in animal research with intra-abdominal pressure and presents evidence for the role of intra-abdominal pressure in the cystometry of normal rats and in animal models of overactive bladder directed at understanding the pathogenesis of the overactive bladder condition. The methodology is also briefly reviewed.

Intravesical OnabotulinumtoxinA Injection for Overactive Orthotopic Ileal Neobladder: Feasibility and Efficacy

Nathan Hoag,Vincent Tse,Audrey Wang,Eric Chung,Johan Gani 대한배뇨장애요실금학회 2016 International Neurourology Journal Vol.20 No.1

The efficacy of intravesical onabotulinumtoxinA (BTXA) in the treatment of overactive bladder (OAB) has been well documented. The use of BTXA injection in orthotopic neobladders is yet to be studied. We present 4 cases of patients injected with intravesical BTXA for overactive orthotopic ileal neobladder. We recorded patient demographics, presenting and follow-up symptoms, urodynamic profiles, and Patient Global Impression of Improvement (PGI-I) scores. The 4 patients reported varying degrees of subjective improvements in the symptoms, including urgency, urge incontinence, and pad usage. Mean followup duration was 8.3 months (range, 5–14 months). Average PGI-I score was 3 (“a little better”) (range, 2–4). To our knowledge, the current study is the first case series examining BTXA injection for orthotopic neobladder overactivity. BTXA injection yielded varying degrees of objective and subjective improvements, without significant complications. Intravesical BTXA injection is feasible and may be considered as a potential treatment alternative for OAB in orthotopic neobladders, although further study is warranted.

Effects of Acute Sacral Neuromodulation at Different Pulse Widths on Bladder Overactivity in Pigs

Huiling Cong,Limin Liao,Yiming Wang,Lingna Zhao,Zhaoxia Wang,Guang Fu,Guoqing Chen 대한배뇨장애요실금학회 2019 International Neurourology Journal Vol.23 No.2

Purpose: Sacral nerve stimulation has been used to treat overactive bladder. This study evaluated the effects of stimulation using different pulse widths on the inhibition of bladder overactivity by sacral nerve stimulation (SNM) in pigs. Methods: Implant-driven stimulators were used to stimulate the S3 spinal nerve in 7 pigs. Cystometry was performed by infusing normal saline (NS) or acetic acid (AA). SNM at pulse widths of 64 μsec to 624 μsec was conducted at the intensity threshold at which observable perianal and/or tail movement was induced. Multiple cystometrograms were performed to determine the effects of different pulse widths on the micturition reflex. Results: AA-induced bladder overactivity reduced the bladder capacity to 46.9%±7.1% of the NS control level (P<0.05). During AA infusion, SNM at 64 μsec, 204 μsec, and 624 μsec increased the bladder capacity to 126.1%±6.9%, 129.5%±7.3%, and 140.1%±7.6% of the AA control level (P<0.05). No significant differences were found among the results obtained using pulse widths of 64 μsec, 204 μsec, and 624 μsec (P>0.05). The actual intensity threshold varied from 0.7 to 8 V. The mean intensity threshold (T visual) for pulse widths of 64 μs, 204 μs, and 624 μs were 5.64±0.76 V, 3.11±0.48 V, and 2.52±0.49 V. T visual for pulse widths of 64 μsec was larger than the other two T visual for pulse widths of 204 μsec and 624 μsec (P<0.05). No significant differences were found among the T visual for pulse widths of 204 μsec and 624 μsec (P>0.05). Conclusions: This study indicated that different pulse widths could play a role in inhibiting bladder overactivity. It is not yet certain which pulse widths increased bladder capacity compared with AA levels, to minimize energy consumption and maintain patient comfort during stimulation, 204 μsec may be an appropriate pulse width for SNM.

Botulinum Toxin in Neurogenic Detrusor Overactivity

Carlos Arturo Levi D’Ancona,Rúiter Silva Ferreira,Mauricio Carneiro Rassi 대한배뇨장애요실금학회 2012 International Neurourology Journal Vol.16 No.3

Purpose: To evaluate the effects of botulinum toxin on urodynamic parameters and quality of life in patients with neurogenic detrusor overactivity. Methods: Thirty four adult patients with spinal cord injury and detrusor overactivity were selected. The patients received 300 units of botulinum toxin type A. The endpoints evaluated with the episodes of urinary incontinence and measured the maximum cystometric capacity, maximum amplitude of detrusor pressure and bladder compliance at the beginning and end of the study (24 weeks) and evaluated the quality of life by applying the Qualiveen questionnaire. Results: A significant decrease in the episodes of urinary incontinence was observed. All urodynamic parameters presented a significant improvement. The same was observed in the quality of life index and the specific impact of urinary problems scores from the Qualiveen questionnaire. Six patients did not complete the study, two due to incomplete follow-up, and four violated protocol and were excluded from the analyses. No systemic adverse events of botulinum toxin type A were reported. Conclusions: A botulinum toxin type A showed a significantly improved response in urodynamics parameters and specific and general quality of life.

Role of Nicotinic Acetylcholine Receptor α3 and α7 Subunits in Detrusor Overactivity Induced by Partial Bladder Outlet Obstruction in Rats

김효신,박웅진,박은영,고준성,황태곤,김준철 대한배뇨장애요실금학회 2015 International Neurourology Journal Vol.19 No.1

Purpose: To investigate the role of α3 and α7 nicotinic acetylcholine receptor subunits (nAChRs) in the bladder, using a ratmodel with detrusor overactivity induced by partial bladder outlet obstruction (BOO). Methods: Forty Sprague-Dawley rats were used: 10 were sham-operated (control group) and 30 were observed for 3 weeks afterpartial BOO. BOO-induced rats were further divided into 3 groups: Two groups of 10 rats each received intravesicular infusionswith hexamethonium (HM group; n=10) or methyllycaconitine (MLC group; n=10), which are antagonists for α3and α7 nAChRs, respectively. The remaining BOO-induced rats received only saline infusion (BOO group; n=10). Based onthe contraction interval measurements using cystometrogram, the contraction pressure and nonvoiding bladder contractionswere compared between the control and the three BOO-induced groups. Immunofluorescent staining and Western blottingwere used to analyze α3 and α7 nAChRs levels. Results: The contraction interval of the MLC group was higher than that of the BOO group (P<0.05). Nonvoiding bladdercontraction almost disappeared in the HM and MLC groups. Contraction pressure increased in the BOO group (P<0.05)compared with the control group and decreased in the HM and MLC groups compared with the BOO group (P<0.05). Immunofluorescencestaining showed that the α3 nAChR signals increased in the urothelium, and the α7 nAChR signals increasedin the urothelium and detrusor muscle of the BOO group compared with the control group. Western blot analysisshowed that both α3 and α7 nAChR levels increased in the BOO group (P<0.05). Conclusions: Alpha3 and α7 nAChRs are associated with detrusor overactivity induced by BOO. Furthermore, nAChR antagonistscould help in clinically improving detrusor overactivity.

Randomized Crossover-Controlled Evaluation of Simultaneous Bilateral Transcutaneous Electrostimulation of the Posterior Tibial Nerve During Urodynamic Studies in Patients With Lower Urinary Tract Symptoms

Florian Girtner,Hans-Martin Fritsche,Florian Zeman,Toni Huber,Maximilian Haider,Christoph Pickl,Maximilian Burger,Roman Mayr 대한배뇨장애요실금학회 2021 International Neurourology Journal Vol.25 No.4

Purpose: Transcutaneous tibial nerve stimulation (TTNS) has proven to be a valuable treatment option for various lower urinary tract conditions, such as overactive bladder syndrome and neurogenic detrusor overactivity. The aim of this study was to investigate acute changes in urodynamic parameters due to bilateral TTNS. Methods: Fifty-one patients (18–87 years; 61% female) with various lower urinary tract symptoms were enrolled in this study. They were single-blinded and randomly assigned to receive simultaneous bilateral TTNS either during their first urodynamic examination, followed by a second round using a placebo stimulation technique, or vice versa. Results: For subjects without signs of anatomical pathologies, the filling volume at the first desire to void (FDV) increased significantly by 54 mL (interquartile range [IQR], 26–81 mL; P<0.01) under the influence of TTNS compared to placebo. The maximum cystometric capacity increased by 41 mL (IQR, 10–65 mL; P=0.02). The median micturition volume of patients with pathological postvoid residual volumes (>100 mL) increased by 76 mL compared to patients without urinary retention (IQR, 6–166 mL; P=0.03). Conclusions: Compared to placebo, simultaneous bilateral TTNS showed significant improvements in bladder functioning, such as delayed FDV, increased maximum cystometric capacity, and reduced urinary retention. Patients with signs of anatomical pathologies did not seem to benefit from TTNS. Further studies need to be conducted to compare the effectiveness of bilateral versus unilateral TTNS.

Effect of low concentrations of hydrogen peroxide on the contractile responses of rat detrusor smooth muscle strips

Han, J.H.,Lee, M.Y.,Lee, S.Y.,Chang, I.H.,Kim, H.J.,Kim, W.,Myung, S.C. North-Holland ; Elsevier Science Ltd 2010 european journal of pharmacology Vol.638 No.1

This study was designed to determine how the contractility of rat detrusor smooth muscle strips changes in the presence of low concentrations of hydrogen peroxide (H<SUB>2</SUB><SUB>2</SUB>. The strips were dissected from the base of Sprague-Dawley rat bladders and their contractile responses to a cumulative increase in H<SUB>2</SUB><SUB>2</SUB>concentration (3x10<SUP>-6</SUP>3x10<SUP>-2</SUP>%) were measured. How the duration of exposure to the fixed concentration of 3x10<SUP>-4</SUP>% H<SUB>2</SUB><SUB>2</SUB>affected contractility was also examined. Moreover, the effect of 3x10<SUP>-4</SUP>% H<SUB>2</SUB><SUB>2</SUB>pretreatment on the response to cumulative increases in the concentrations of phenylephrine or acetylcholine (10<SUP>-8</SUP>10<SUP>-4</SUP>) was assessed. To elucidate the mechanism by which H<SUB>2</SUB><SUB>2</SUB>induced contraction, we examined the effect of pretreatment with 10nM Y-27632, 10μM indomethacin, 10μM SQ29548, 10μM verapamil, 10μM vitamin E, or 1μM Bay-K 8644 on the contractile responses generated by cumulatively increasing the concentration of H<SUB>2</SUB><SUB>2</SUB> H<SUB>2</SUB><SUB>2</SUB>induced contractile responses in Ca<SUP>2+</SUP>free physiological solution were also examined. Low concentrations of H<SUB>2</SUB><SUB>2</SUB>increased the contractile responses of the strips in a dose-dependent manner but increasing treatment duration decreased these responses. H<SUB>2</SUB><SUB>2</SUB>pretreatment significantly augmented the contraction induced by phenylephrine (P<0.05) but had no effect on the response to acetylcholine. Pretreatment with Y-27632, indomethacin, vitamin E, verapamil, and Bay-K 8644 significantly inhibited the H<SUB>2</SUB><SUB>2</SUB>induced contraction (P<0.05). SQ 29548-pretreatment had no effect. H<SUB>2</SUB><SUB>2</SUB>could not increase the contractile responses in Ca<SUP>2+</SUP>free physiological solution. Thus, low concentrations of H<SUB>2</SUB><SUB>2</SUB>may directly affect detrusor smooth muscles and thereby induce detrusor overactivity.

Relationship between Lower Urinary Tract Dysfunction and Dementia

Na Hae Ri,조성태 대한치매학회 2020 Dementia and Neurocognitive Disorders Vol.19 No.3

Lower urinary tract dysfunction (LUTD) is a common health challenge in dementia patients with significant morbidity and socioeconomic burden. It often causes lower urinary tract (LUT) symptoms, restricts activities of daily life, and impairs quality of life. Among several LUT symptoms, urinary incontinence (UI) is the most prominent storage symptom in the later stages of dementia. UI in patients with dementia results not only from cognitive impairment, but also from urological defects such as detrusor overactivity. Management of LUTD in patients with dementia is based on multiple factors, including cognitive state, functional impairment, concurrent comorbidities, polypharmacy and urologic condition. Behavioral therapy under caregiver support represents appropriate treatment strategy for UI in these patients. Pharmacological treatment can be considered in patients refractory to behavioral therapy, but it is more effective when combined with behavioral therapy. Antimuscarinics and mirabegron, a beta-3 receptor agonist, are effective for managing storage symptoms involving the LUT. However, anticholinergic side effects in elderly subjects are a concern, particularly when there is a risk of exacerbating cognitive impairment with prolonged use of antimuscarinics. Proper recognition and treatment of LUTD in dementia can improve quality of life in these patients.

Correlation between Overactive Bladder Syndrome and Obsessive Compulsive Disorder in Women

Keun-Soo Ahn,Hyun-Pyo Hong,권혁중,Ah-Leum Ahn,Eun-Jung Oh,최재경,조동영 대한가정의학회 2016 Korean Journal of Family Medicine Vol.37 No.1

Background: Overactive bladder syndrome is characterized by urinary urgency, usually accompanied by Frequent urination and nocturia, with or without urgent urinary incontinence. There must be the absence of causative infection or pathological conditions. Overactive bladder syndrome is related to mental disorders, particularly depression and anxiety. However, obsessive-compulsive symptoms are investigated much less frequently. The purpose of the present study was thus to assess obsessive-compulsive symptoms in overactive bladder syndrome patients. Methods: Fifty-seven women patients with overactive bladder syndrome and fifty-seven women without it (age matched control group) were prospectively enrolled. They completed the overactive bladder syndrome-validated 8-question screener and the Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire at the same time they visited the clinic. Patients were compared with controls on the Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire and its checking, tidiness, doubting, and fear of contamination components. Results: Patients showed more obsessive traits than controls on the Korean version of the Maudsley Obsessional- Compulsive Inventory Questionnaire total score (P=0.006) and on the checking subscale (P=0.001). Odds ratio for the overactive bladder syndrome group’s obsessive-compulsive symptoms traits (score≥14) was 5.47 (P=0.001). The Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire total score was associated with the overactive bladder syndrome-validated 8-question screener score in patients (P=0.03). Conclusion: Obsessive-compulsive symptoms may constitute an important aspect of the psychiatric profile of overactive bladder syndrome patients. The severity of obsessive-compulsive symptoms seems to be related to the degree of the overactive bladder syndrome severity. Clinicians may consider screening women with overactive bladder syndrome for obsessive-compulsive symptoms.