DVSUIpaper.docx

DVSUIpaper.docx

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DVSUIpaper

DysfunctionalVoidinganditsAssociationwithStressUrinaryIncontinenceinWomen

DanfengXu,M.D.,ChuangyuQu,M.D.,JizhongRen,M.D.,

HongMeng,M.D.,YouhuaZhu,M.D.,ZhilianMin,M.D.,

YachengYao,M.D.,XingangCui,M.D.,YiGao,M.d.,JieChen,M.D.,

YushanLiu,M.D.,andLeiYin,M.D.

FromtheDepartmentofUrology,ChangzhengHospital,

SecondMilitaryMedicalUniversity,Shanghai,China

（D.F.X.,C.Y.Q.,J.Z.R.,Y.H.Z.,Z.L.M.,Y.C.Y..,

X.G.C.,Y.G.,J.C.,Y.S.L.,L.Y.）;theInstituteofHealthstatistics,

SecondMilitaryMedicalUniversity,Shanghai,China

（H.M.）.AddressreprintrequeststoDr.ChuangyuQuat

theDepartmentofUrology,ChangzhengHospital,SecondMilitaryMedical

UniversityofPLA,Shanghai,China,200003,oratqu_cy@.

ABSTRACT

BACKGROUND

Dysfunctionalvoiding（DV）isanabnormalityofbladderemptyinginneurologicallynormalindividualscharacterizedbyaminusderivedelectromyographyvariableTLvalue.Weobserveditsoccurrenceinpatientswithstressurinaryincontinence（SUI）.ItwassupposedthatthistypeofDVisasecondaryfindingandSUImayberesponsibleforthisabnormalitythroughguardingreflexofthesacralspinalcord.Basedonthislaboratoryexperienceandclinicalresults,ananalysisofalargepopulationofwomenwithSUIwasconducted.

METHODSFrom2002to2008,atotalof360femalepatientswithSUIwereenrolledinaprospectivelong-termstudytoassesstheprevalenceofDVinwomenwithSUIanditsimpactonotherclinicalandurodynamicfeatures.Accordingtotheelectromyography（EMG）characteristicsduringthevoidingphase,thepatientsweredividedintotwogroups:

group1（n=99）characterizedbySUIwithDV,andgroup2（n=261）bySUIwithoutDV.Atthesameperiod,femalepatientscomplainedoflowerurinarytractsymptoms（LUTS）withouteitherSUIorDVweregroupedascontrol（n=106）,markedasgroup3.Allsubjectsunderwentmultichannelcomprehensiveurodynamics,thevariablesofthedetrusorandurethralsphincterobtainedfromthefillingphase,voidingphaseandurethralpressureprofilometry（UPP）phasewerecomparedamongthe3groups.Duringthisperiod,atotalof150patientswithSUIunderwenttheprocedureofTVT（tension-freevaginaltape）.Amongthem,55patientswereingroup1（SUIwithDV）,and95patientsingroup2（SUIwithoutDV）.AftertheprocedureofTVT,thewomenwerefollowedupregularly.

RESULTSDuringthisperiod,atotalof1900femalepatientswereexaminedfortheirLUTSinChangzhengHospital,amongwhom,360withSUI（18.9%）.TheDVprevalenceingeneralwasaveraged27.5%（rangingfrom14.5%to51.4%peryear,P<0.001）andtheprevalenceofDVgraduallyincreased（P<0.001）.TherewerenosignificantdifferencesbetweenSUIwithandwithoutDV,insuchvariablesasvoiding/24h,freeQmax,maximumcystometriccapacity（MCC）,stressleakpointpressure（SLPP）,PdetQman,Qmax,andmaximalurethralclosurepressure（MUCP）（P>0.05）exceptfunctionalprofilelength（FPL）.ComparedwiththeSUIpatients,thecontrolgrouphadhigherobstructiveextent（lowerQmaxandfreeQmax,higherfrequency,PdetQmaxandMUCP）.Thesubjectiveandobjectiveoutcomemeasureshowedthatthecurerateswere83.6%（46/55）and90.5%（86/95）inthegroupswithandwithoutDV,respectively（P>0.05）.

CONCLUSIONSDVassociatedwithSUIisaclinicalentity,itsprevalencefromour7-yearobservationis27.5%.Thispathologicalvariantmaycomefromanextensionofguardingreflexintothevoidingphaseevokedbyleakedurineintheurethra.TherewerenosignificantdifferencesintheurodynamicvariablessuchasPdetQmax,Qmax,MUCP,andinthesurgicaloutcomesofTVTprocedurebetweenthosewithDVandthosewithoutDV.Althoughitisapathologicalvariant,itisasecondaryfindingtoSUI,andthepatientsinvolvedwithoutothersymptomsbesidesSUIshouldonlybefollowedup.

Dysfunctionalvoiding（DV）isanabnormallylearnedspectrumofbehavioroftenevolvingfromattemptstosuppressimpendingoractivebladdercontractionbyinappropriatelycontractingthepelvicfloormuscles,therebytighteningtheurinarysphinctercomplex.1ApartfromtheidiopathictypeofDV，whichwehaveshownclearlybymeansoftransdermalperinealelectromyography（EMG）withtwoneedle-guided-wireelectrodes,andpresentedonitsmedicaltherapyexperiencein2007,2wefurtherobserveditsoccurrenceinpatientswithstressurinaryincontinence（SUI）,amajorcauseof“globalburdenoffemalepelvicfloordisorder”.3ThisphenomenonconfirmedbyEMGdatahasnotyetbeendescribedclearlyelsewhere,4,5andwesupposethatthistypeofDVisasecondaryfindingandSUImayberesponsibleforthisabnormalitythroughguardingreflexofthesacralspinalcord.6,7

Thisreflex,asamechanisminthemaintenanceofurinarycontinenceduringstress（elevationsinintra-abdominalpressure）,isinvolvedintheselfprotectionbyanactivecontractionofstriatedmuscleoftheexternalurethralsphincter.6

Althoughtheterm-DVdescribesmalfunctionduringthevoidingphaseonlyandsaysnothingaboutthestoragephaseinchildren,inwomenDVmayresultinbothstoragesymptomsandemptyingsymptoms.Frequencyandurgencywerethemostcommonpresentingsymptomsin82%ofcasesinNitti’sseries.8Ourfindingsweresimilar.Inourpreliminaryurodynamicresults,wehavefoundcoexistenceofSUIandDVinwomensince2002.Basedonthislaboratoryexperienceandclinicalresults,weconductedaprospectivelong-termanalysisofalargepopulationofwomenwithSUItodeterminetheprevalenceofSUI-associatedDVandtheirclinicalandurodynamicfeatures.

METHODS

SelectionandEnrollmentofPatients

Thisstudywasdoneprospectivelyandconsecutively,conductingfromJune2002toJune2008,andthelocalethicalcommitteegranteditsapprovalandallparticipantsprovidedwritteninformedconsent.FemalepatientswhodemonstratedSUIonurodynamicswereeligibleforparticipation.Allpatientswereevaluatedusingastandardizedprotocol,includingmedicalhistory,acompletephysicalexaminationincludingagynecologicandneurologicexamination,includingspinalcordMRIifnecessary,toexcludeneuropathyaffectingthelowerurinarytract,urineanalysisandculture,urinarytractandgynaecologicalultrasonography,acoughprovocationstresstestinthestandingposition,a24-hourpadweighingtest,a3-dayvoidingdiaryandresidualurinemeasurementsandsynchronousmultichannelurodynamics.Allpatientswerenative-bornChinese.

Patientswhocannotvoidinsittingposition,andthosewithinfravesicalobstruction,neurogenicbladderdysfunction,congenitalmalformationofthelowerurinarytract,demonstrabledetrusoroveractivity,detrusorhypocontractility,urinarytractinfection,interstitialcystitis,previouspelvicradiation,anddiabeticneuropathywereexcluded.

UrodynamicStudies

Themultichannelurodynamics（UrovisionJanusⅤ,Life-Tech,TX,USA）providedanestimateofmaximumuroflowrate（freeQmax）,fillingcystometrography（CMG）includingstressleakpointpressure（SLPP）determination,voidingpressure-flowstudy（PFS）,simultaneoustransdermalperinealelectromyography（EMG）andurethralpressureprofilometry（UPP）.AllterminologyconformstothatproposedbytheInternationalContinenceSocietyunlessotherwisestated.9Duringthefillingphase,thevesicalpressure（Pves）,abdominalpressure（Pabd）,detrusorpressure（Pdet,=Pves-Pabd）andtransdermalperinealEMGweremonitoredsimultaneouslywiththetransducers,usingsalineataninfusionrateof70mL/min.ThetransdermalperinealEMGwasobtainedusingtwotransdermalneedle-guided-wireelectrodes.ThebladderwasfilledcontinuouslyandSLPPwasdefinedasleakageobservedduringacoughstresstestandlabeledasLKintheCMG.Whenthemaximumcystometriccapacity（MCC）wasreachedthefillingprocessstoppedandthenthevoidingphasebegan.Theurinaryflowratesanddetrusorpressuresweremeasuredbyaskingthepatienttovoidattheendofbladderfillinginsittingposition.TheQmaxandthePdetQmaxfromPFSwereplottedforeachpatientaccordingtotheICSguidelinesandShaefernomogram.Detrusoroveractivitywasdiagnosedwhenanuninhibiteddetrusorcontractionof>10cmH2Owasdetectedduringfilling.FinallytheUPPwasexecutedandthemaximumurethralclosurepressure（MUCP）andthefunctionalprofilelength（FPL）wererecorded.

Dysfunctionalvoiding（DV）wasdiagnosedwhentherewasincreasedexternalsphincteractivityduringvoluntaryvoiding,asshownbytheincreasedsphincteractivitywithasustaineddetrusorcontraction.Inordertocomparetheextentofdysfunctionalvoiding,wehaveintroducedanewEMGvariable,TLvalue,whichisthelogarithmoftheratiooftheelectricpotentialsbetweenbeforevoiding（whenthesphinctershouldbetense）andatQmax（whenthesphinctershouldbeloose）.2ThevalueshouldbepositiveinnormalsubjectswithoutDVandnegativeinsubjectswithDV,increasingwhentheDVimprovesorrecoverstonormal.

StudyDesign

TheparticipantswithSUIweredividedintotwogroups,group1characterizedbySUIwithDV,andgroup2characterizedbySUIwithoutDV.TheallocationwasdeterminedbytheirvoidingPFSandsimultaneousEMGexpressionsduringthevoidingphase.Furthermore,acomparisongroup,group3ascontrol,wascomposedofwomencomplainedofLUTSandnodemonstrableSUIandDVcharactersduringthesameperiod.Theageofpatients,dateofassessmentandenrolment,historyofincontinence,thefrequencyofvoidingper24h,andvariousurodynamicvariables（suchas:

freeQmax,PdetQmax,Qmax,MCC,SLPP,TLvalue,outletobstructionextentgrading（usingShaeferNomogram）,MUCP,andFPL）wererecordedandcomparedbetweengroups.

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