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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