Urethral pressure variations in women with neurourological symptoms: II. Relationship to urethral smooth muscle

Simultaneous urethrocystometry and electromyography from the urethral striated muscle during bladder filling was performed on female patients complaining of neurourological symptoms. Their maximum urethral pressure varied between 20 and 84 cm H₂O. To study the effect of the urethral smooth muscle on the urethral pressure variations, a bilateral pudendal block was applied successfully in 12 patients. It was found that in 1 patient the urethral pressure variations were caused by the urethral striated muscle only, in 4 patients they were caused mainly by the urethral striated muscle, in 2 other patients they were caused equally by urethral striated and smooth muscle, and finally in 5 patients mainly by urethral smooth muscle. By eliminating the urethral striated muscle activity by pudendal block the maximum urethral pressure was reduced 20 to 84%.     

Stress urinary incontinence: An alternative concept of pathogenesis

A urodynamic study was done on 14 normal subjects and 24 with stress urinary incontinence (SUI), aiming to elucidate SUI etiology. All were multiparous women; 8 of the SUI patients also had partial fecal incontinence. The investigations comprised measuring the vesical and urethral pressures before and after testing external urethral sphincter anesthesia, determination of the functional urethral length and recording of the external urethral sphincter EMG, the straining-urethral reflex and the perineal nerve terminal motor latency (PNTML). The results in both normal and SUI subjects showed that coughing caused both vesical and urethral pressure increase, while an increase in vesical pressure only on external urethral sphincter anesthesia. In SUI patients, the urethral pressure at rest and on coughing was significantly lower (P<0.001) and the functional length shorter than in normal subjects (P<0.01). The external urethral sphincter EMG activity was below normal. The latency of the straining-urethral reflex as well as the PNTML were longer than normal (P<0.01). Results suggest that urethral pressure increase on coughing is effected by external urethral sphincter contraction and is not transmitted by increased intraabdominal pressure, as evidenced by the urethral sphincter anesthesia test and physioanatomic studies. The vesical and urethral descent in SUI is likely to be related to levator subluxation and sagging, which causes levator dysfunction. The cause of the weak external urethral sphincter and the prolonged straining-urethral reflex latency seems to be neurogenic, due probably to stretch of the pudendal nerve in the pudendal canal, as evidenced by the prolonged PNTML.     

Urethral injury: Experimental study

The present experiment was designed to study several challenging therapeutic questions that remain disputable or unanswered: (1) Whether urethral healing post-trauma is influenced by the use of an indwelling urethral stent as an adjunct to suprapubic diversion; (2) the incidence of urethral stricture formation after immediate or delayed urethral repair; (3) the incidence of urethral stricture formation after partial or complete urethral disruption; and (4) further assessment of radiographic findings in urethral injury. Herein is described the final conclusions we found to be relevant to this experiment.     

Urethral sensation following reconstructive pelvic surgery

Introduction and hypothesis

Most urethral neuromuscular function data focus on efferent rather than afferent innervation. We aimed to determine if changes exist in urethral afferent nerve function before and after reconstructive pelvic surgery (RPS). Secondarily, we compared afferent urethral innervation in women with and without stress urinary incontinence undergoing RPS.

Methods

Participants underwent current perception threshold (CPT) and urethral anal reflex (UAR) testing prior to surgery and again post-operatively. Wilcoxon signed ranked test and Spearman’s correlations were used and all tests were two-sided. p?=?0.05 was considered to indicate statistical significance.

Results

Urethral CPT thresholds increased significantly after RPS, consistent with decreased urethral afferent function. Pre-operative urethral CPT thresholds at 5 and 250 Hz were lower in SUI women (10 [IQR 5–29], 40 [32–750]) compared with continent women (63 [14–99], 73 [51–109]; p?=?0.45, p?=?0.020), signifying increased urethral sensation or easier activation of urethral afferents in SUI women.

Conclusions

Reconstructive pelvic surgery is associated with a short-term deleterious impact on urethral afferent function, as demonstrated by the higher levels of stimuli required to activate urethral afferent nerves (decreased urethral sensation) immediately after RPS. Women with SUI required lower levels of stimuli to activate urethral afferent nerves prior to RPS, although UAR latencies were similar regardless of concomitant SUI.     

排尿期尿道超声显像在男性尿道疾病诊断中的应用

目的探讨排尿期尿道超声显像在男性尿道疾病诊断中的临床应用价值。方法对58例尿道疾病患者及8例正常尿道行排尿期尿道的经会阴及经阴茎超声检查。其中膀胱颈口尿道梗阻8例，良性前列腺增生（BPH）致尿道梗阻16例，急性尿道炎19例，慢性尿道炎7例、合并狭窄2例，尿道外伤性狭窄2例，尿道瘘2例，假性尿道、尿道炎性息肉、尿道尖锐湿疣和尿道癌各1例。结果排尿期尿道超声显像可动态观察膀胱颈口开放及后尿道顺应性扩张情况，膀胱颈口梗阻及良性前列腺梗阻表现为随着膀胱底及基底部下降，尿道内口被挤压形成颈口狭窄，而其以下水平尿道扩张正常或降低，患者愈用力排尿，梗阻愈加重。对急慢性尿道炎可明确炎症部位、范围、程度、有无脓栓附着等，同时对尿道慢性炎性狭窄或外伤性狭窄以及假性尿道、尿道瘘、尿道赘生物及恶性肿瘤等显像良好。结论排尿期尿道超声检查为非侵入性检查、可重复性强，对尿道疾病的诊断及治疗效果评价具有重要的临床意义。     

Urethral pathology

In the present review the eligible data on urethral pathologies are critically analysed, with special attention given to unresolved controversies in this topic. The entities discussed are as follows: female circumcision as a ritualistic tradition, with many associated complications; prostatourethritis and urethral syndrome; urethral diverticula as an overlooked rare pathology in urological practice; urethrorectal fistula; pelvic fracture urethral injuries and its current standard treatment algorithm; and urethral strictures and new endoscopic or surgical reconstructive techniques.     

闭合性尿道球部损伤不同手术治疗效果与术后狭窄处理分析

目的比较闭合性尿道球部损伤早期行耻骨上膀胱造瘘术与膀胱镜下留置尿管术的临床效果及术后狭窄处理。方法回顾性分析2012年6月至2017年6月就诊的57例闭合性尿道球部损伤患者,耻骨上膀胱造瘘患者24例(造瘘组),膀胱镜下留置尿管患者33例(置管组)。随访期间发生狭窄的患者,根据狭窄程度行微创手术(内镜下尿道内切开术或尿道扩张术)或开放修复手术。比较两组患者术后狭窄的发生率、狭窄段长度、勃起功能障碍(ED)发生率。比较早期行膀胱镜下留置尿管治疗后发生狭窄的患者与早期行耻骨上膀胱造瘘治疗后发生狭窄的患者经微创手术治愈的比例。结果造瘘组和置管组术后狭窄发生率分别为33.33%(8/24)和63.64%(21/33),差异有统计学意义(P<0.05);狭窄段长度分别是(1.17±0.42)cm和(1.38±0.44)cm,差异无统计学意义(P>0.05),造瘘组与置管组ED发生率分别是4.17%(1/24)和6.06%(2/33),差异无统计学意义(P>0.05)。早期行膀胱镜下留置尿管治疗后发生狭窄的患者与早期行耻骨上膀胱造瘘治疗后发生狭窄的患者通过微创手术治愈比例的差异无统计学意义(χ^2=2.032,P=0.154)。结论尿道球部损伤患者早期行耻骨上膀胱造瘘可能降低术后尿道狭窄的发生,但对狭窄段长度及ED的发生可能无影响。     

尿道损伤的分类处理244例分析

目的：探讨不同类型尿道损伤的处理方法。方法：回顾性分析244例尿道损伤的分类和治疗资料。结果：急性尿道损伤后的非尿困难者,行耻骨上膀胱穿刺加短期保留导尿;不能排尿,而非后尿道损伤,早期行尿道端端吻合修补术;后尿道断裂伤,早期行会师加牵引术;陈旧性尿道损伤,而非后尿道狭窄或闭锁,行瘢痕切除尿道对端吻合;后尿道狭窄,行瘢痕激光气化切除。结论：对尿道损伤的处理应根据损伤部位及损伤程度进行恰当分类并选用不同的治疗方法。     

Urethral Closure Pressure Changes with Age in Men

Purpose

The natural history of external urethral sphincter function in elderly men is unknown.

Materials and Methods

In 257 men 45 to 88 years old external sphincter function changes with aging were analyzed by urodynamic studies, including functional urethral length, maximal urethral pressure, sphincter length and maximum urethral pressure during voluntary contraction.

Results

Mean functional urethral length was 51.9 mm. and there was no statistical decrease with age. However, sphincter length decreased with age from 24.3 to 14.8 mm., maximal urethral pressure from 88.7 to 55 cm. water and maximal urethral pressure during voluntary contraction from 221.4 to 166.3 cm. water.

Conclusions

Sphincter function according to urethral pressure profile decreases with patient age.     

Anterior urethral diverticulum: A rare presentation

Congenital anomalies of the urogenital tract are the most common anomalies found in the foetus, neonates and infants, but anterior urethral valves and diverticula are rare. Here, we present a case with congenital anterior urethral diverticulum associated with patent ductus arteriosus and polydactyly.KEY WORDS: Anterior urethral cyst, anterior urethral diverticulum, anterior urethral valve, congenital, patent ductus arteriosus, polydactyly     

Urethral pressure variations in women with and without neurourological symptoms

Simultaneous urethrocystometry was performed in 93 females without and 174 patients with neurourological symptoms. Both populations were divided into three age groups. The urethral pressure variation (ΔMUP) was calculated as the difference between the highest and the lowest maximum urethral pressure observed during 1 minute. In all age groups, both the highest and the lowest maximum urethral pressure recorded during bladder filling were significantly higher in the normal females than in the patients. There was, however, no significant difference in the degree of ΔMUP between normal females and patients in the different age groups. Typical urethral pressure variation was also observed during physiological bladder filling. Thus, urethral pressure variation in itself is a physiological phenomenon. With less difference between the lowest maximum urethral pressure and the bladder pressure, the possibility of leaking urine is increased. A urethral pressure decrease may therefore cause leakage in a patient but not in a normal female. More than 50% of the normal females had a urethral pressure variation of more than 20 cm H₂O. The previous definitions of urethral pressure variations (unstable urethral pressure, urethral instability), which describe the condition as pathologic when the pressure varies more than 10, 15, or 20 cm H₂O, can therefore no longer be considered useful.     

尿道瘢痕组织胶原酶活性及TIMP-1表达的研究

目的　比较正常尿道组织和尿道瘢痕组织中胶原酶活性以及金属蛋白酶组织抑制剂 - 1(TIMP- 1)的表达 ,探讨其对尿道瘢痕组织降解的影响。　方法　取手术切除的尿道狭窄段瘢痕组织和脑死亡患者的正常尿道组织各10例 ,采用 EL ISA法检测组织中胶原酶活性及逆转录 -聚合酶链反应 (RT- PCR)检测 TIMP- 1m RNA的表达。　结果　尿道瘢痕组织中胶原酶的活性为 (15 .32± 2 .2 9) U,正常尿道组织的胶原酶活性为 (2 4 .6 7± 6 .78) U,瘢痕组织的胶原酶活性低于正常尿道组织 ,差异有统计学意义 (P<0 .0 1)。与正常尿道组织比较 ,尿道瘢痕组织的 TIMP- 1表达明显升高、差异有统计学意义 (P<0 .0 5 )。　结论　 TIMP- 1表达升高、胶原酶活性降低影响了尿道瘢痕组织的降解 ,可能是尿道瘢痕增生的原因之一。     

Traumatic Posterior Urethral Injury and Early Realignment Using Magnetic Urethral Catheters

Purpose

We determined the success of early urethral realignment using magnetic urethral catheters.

Materials and Methods

We retrospectively reviewed the records of 13 patients with complete urethral disruption treated with endourological realignment 0 to 11 days after injury using coaxial magnetic urethral catheters.

Results

Urethral realignment was established in 11 of the 13 patients (85%) using magnetic urethral catheters. Of the 10 patients for whom followup was available urethral strictures developed in 5 (50%) a mean of 6.1 months after realignment, necessitating a mean of 1.4 corrective procedures per patient. Impotence was noted in 1 of 7 patients (14%) and no urinary incontinence developed after realignment.

Conclusions

Urethral realignment within 2 weeks of injury using magnetic urethral catheters is a safe and simple technique with minimal morbidity. The stricture formation, impotence and incontinence rates of this technique are comparable to those reported for delayed urethroplasty. We advocate early realignment using magnetic urethral sounds as an alternative treatment for traumatic urethral disruption.     

小儿尿道损伤的诊断与治疗

目的：探讨小儿尿道外伤及外伤后尿道狭窄的诊治经验。方法：在8例新鲜完全性后尿道断裂患儿中,3例行经耻骨上与会阴入路的尿道修复术,2例行尿道会师术,2例行膀胱造瘘术,1例女童行经耻骨后尿道吻合术。在18例陈旧性后尿道外伤患儿中,10例行经尿道内切开（TUR）术,4例行经耻骨、会阴联合入路修复术,4例行经会阴修复术。结果：8例新鲜后尿道断裂患儿中,术后出现尿道狭窄5例,不完全尿失禁1例。18例陈旧性尿道蛱雅患儿中,行TUR的成功率为60．0％,经会阴及经耻骨、会阴联合入路行尿道修复术的成功率为91．7％,有不完全尿失禁5例,会阴尿道造瘘尚未修复1例。结论：后尿道外伤的急症处理非常重要,如患儿情况允许,应尽量行经耻骨、会阴联合入路尿道修复术。经尿道内切开适用于绝大多数单纯性后尿道狭窄,经耻骨、会阴联合入路或经会阴修复尿道适用于复杂性后尿道狭窄或TUR失败者。     

Urethroplasty with dorsal oral mucosa graft in female urethral stenosis

IntroductionFemale urethral stenosis is not a very common pathology and its treatment is controversial. Therapeutic options vary from urethral dilatation and internal urethrotomy to other more complex reconstructive surgical techniques. The use of oral mucosa grafts to treat urethral stenosis has provided excellent long-term results in men, however there are few studies on their use in female urethral stenosis. We present our experience in the management of urethral stenosis using dorsal oral mucosa grafting.Materials and methodsWe present 2 cases of female patients with a history of repeated urinary tract infections associated with low obstructive uropathy. In both cases, we encountered distal urethral stenosis, where both were treated with urethral plasty by means of dorsal oral mucosa grafting.ResultsThe surgery took place without complications. Hospitalization time was 24 hours in both cases. The catheter was removed on the tenth postoperative day. The urethrocystography showed good urethral calibre with no signs of urinary fistula. After a mean follow-up of 18 months, neither patient presented symptoms of low obstructive uropathy or urinary incontinence.ConclusionsUrethroplasty with dorsal oral mucosa grafting is a reproducible and effective therapeutic option for the treatment of urethral stenosis in women.     

The effect of urethral pressure variation on detrusor activity in women

The purposes of this study were to confirm previously described patterns of urethral pressure variation and to establish criteria for their diagnosis. The effect of urethral pressure variation on detrusor activity was also examined. The study involved a retrospective review of the computerized cystometric tracings from a 26-month period. Forty-one patients had artefact-free satisfactory tracings demonstrating urethral pressure variation, detrusor instability and/or gradual detrusor pressure increase. These tracings were stored on a computer program which permitted real-time second-by-second review. Statistical analysis was done using Fisher's exact test and an independentt-test. Three patterns of urethral pressure variation were identified: rapid pressure variation (RPV), gradual pressure variation (GPV) and stress-induced transient urethral relaxation (SITUR). RPV was associated with onset at low bladder volumes (independentt-test,P=0.02) and with detrusor instability (Fisher's exact test,P<0.001). GPV began at high bladder volumes (Fisher's exact test,P<0.001). SITUR was not associated with any specific pattern of urethral pressure variation or detrusor pressure change. Analysis of tracings of the patients with a combination of rapid urethral pressure variation and detrusor instability revealed a statistically significant increased frequency of urethral relaxation as the primary event precipitating an unstable detrusor contraction (Fisher's exact test,P<0.003). In conclusion, three different patterns of urethral pressure variation were identified. Rapid pattern urethral pressure variation is closely associated with detrusor instability. Further study of urethral pressure variation may help to elucidate the pathophysiologic mechanism responsible for idiopathic unstable detrusor contractions.Editorial Comment: This investigation includes very interesting and clinically important findings. The authors describe three patterns of urethral pressure variation and their relation to the detrusor activity. Taking these activities of the urethra into consideration, especially the relationship between detrusor instability and rapid urethral pressure variation, we may select the reasonable and effective therapeutic modality for female urinary incontinence. This study is timely, adding pertinent information for clinical decision-making.     

The urethral syndrome

The urethral syndrome is defined as lower urinary tract symptoms in women in the absence of bladder bacteriuria. It is a common disorder in general practice in Saudi Arabia. The aetiology and pathogenic factors involved in its development are still incompletely understood. Many factors have been suggested as causative of this syndrome, including non-specific infections, urethral obstruction and spasm, senile atrophy, psychosomatic and traumatic factors. An aetiological diagnosis should be made if possible and this will depend on clinical examination, mid-stream urine specimen for quantitative culture and microscopy. Cervical and urethral swabs for microscopy and culture are necessary when infection with urethral pathogens such asC. trachomatis andN. gonorrhoea is suspected. Urethral calibration and uroflowmetry may be needed in some patients. Treatment with a course of tetracycline is indicated for patients with urethral syndrome who have pyuria, urethral dilatation for patients with urethral syndrome secondary to stenosis, and skeletal and smooth muscle relaxants when spasm is found to be the cause. Local vaginal oestrogen application is effective in the treatment of urethral syndrome secondary to hypoestrogenaemia.     

Treatment of Urethral Stricture Disease by Internal Urethrotomy,Dilation, or Stenting

Management of urethral strictures depends on the characteristics of each individual case and remains a great challenge in reconstructive urology. Treatment of anterior urethral strictures usually starts with minimally invasive procedures, such as urethral dilatation or internal urethrotomy. The popularity of these methods is based on the simple application, the low complication rate, and the fact that most general urologists do not perform open urethroplasty. These methods offer faster recovery, minimal scarring, and fewer infections, although recurrence is always possible. Success depends on adequate vascularity within the underlying spongiosal tissue, which may substantially increase the failure rate. Because the recurrence rate has remained higher than it was in past decades, various modifications of urethral stricture treatment have been suggested, including laser urethrotomy and urethral stents. Since the late 1980s, two different approaches have been studied to prevent scaring contraction: permanent stent versus temporary stents left indwelling for a limited time and then removed. Although the first reports seemed to promise excellent outcomes, longer follow-up began to cast doubt on the usefulness of urethral stenting as a primary treatment modality for urethral stricture disease. The purpose of our study was to evaluate the published literature with respect to any new information on minimally invasive procedures in the treatment of urethral strictures.Patient summaryThe optimal indications for dilatation or internal urethrotomy are simple bulbar strictures <2 cm without spongiofibrosis or history of previous treatment. Recurrent urethral strictures after repeated interventions are usually more complex and can render the definite open urethral surgery more difficult.     

Urethral pressure variations in women with neurourological symptoms: I. Relationship to urethral and pelvic floor striated muscle

Simultaneous urethrocystometry and electromyography (EMG) of the urethral and pelvic floor striated muscle were performed in 42 gynecological patients with neurourological symptoms. Their maximum urethral pressure varied between 20 and 124 cm H₂O. A correlation analysis was performed between the maximum urethral pressure and the integrated EMG of the urethral striated muscle and the pelvic floor striated muscle. The analyses were performed on results obtained in 1-min periods during bladder filling before first desire to void was reported, when first desire to void was reported, and when a strong desire to void was reported. In 21 patients no correlation was found between the urethral and pelvic floor striated muscle activity and the maximum urethral pressure at any stage of bladder filling. In the other 21 patients a correlation was found in at least 1 of the 3 stages. At all stages of bladder filling a correlation was found significantly more often between the maximum urethral pressure and the striated urethral muscle EMG than between the maximum urethral pressure and the striated pelvic floor muscle EMG. Thus, activity of the urethral striated muscle cannot be reliably studied in an EMG recording from the pelvic floor striated muscle. In the same patient, periods with a correlation could be succeeded by periods without a correlation. Thus, the urethral pressure variations may in the same patient sometimes be caused mainly by the urethral striated muscle and sometimes mainly by the urethral smooth muscle.     

Observations on the function of the female urethra: I: relation between maximum urethral closure pressure at rest and urethral hypermobility

AIMS: To study the relation between maximum urethral closure pressure at rest and urethral hypermobility in female patients. PATIENTS AND METHODS: We selected 255 patients aged 20 years and older, with a stable bladder on multichannel urodynamics, without known neurological pathology, and without a history of pelvic or anti-incontinence surgery. A resting urethral pressure profile and the degree of urethral hypermobility were registered. Two-tailed analyses of variance (ANOVA) with Fisher's post-hoc tests were used to detect any statistically significant difference (P < 0.05) in urethral closure pressure between groups with varying degrees of urethral hypermobility. RESULTS: Mean age was 45.6 +/- 12.7 (range 20-77) years. Mean maximum urethral closure pressure for the entire group was 62.7 +/- 29 (range 10-150) cm of water. A statistically significant inverse relationship was found between age and maximum urethral closure pressure (r = 0.489, P < 0.0001) when both analyzed as continuous variables, and with age categorized in 10-year increments (P < 0.0001). When comparing mean urethral closure pressure in each group examined for urethral hypermobility, a statistically significant difference was noted when grades I, II, and III were compared to grade 0 hypermobility. No significant difference was observed when grades I, II, and III were compared to each other. Even if statistically non-significant, there exists an inverse relationship between the degree of urethral hypermobility and the maximum urethral closure pressure: a higher hypermobility is associated with a lesser urethral closure pressure. CONCLUSIONS: Urethral closure pressure falls significantly when urethral hypermobility is present. This decrease is not related to patient's age or parity. Our observations demonstrate an inverse relation between urethral closure pressure and the degree of cysto-urethrocele. As hypermobility increases, closure pressure decreases, even if this decrease does not reach the level of statistical significance.