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1620 URODYNAMIC FINDINGS IN PATIENTS WITH DIABETES MELLITUS AND LOWER URINARY TRACT SYMPTOMS
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THE JOURNAL OF UROLOGY姞
Vol. 183, No. 4, Supplement, Tuesday, June 1, 2010
1620 URODYNAMIC FINDINGS IN PATIENTS WITH DIABETES MELLITUS AND LOWER URINARY TRACT SYMPTOMS Doreen E. Chung*, Bobby B. Najari, Richard K. Lee, Steven A. Kaplan, Alexis E. Te, New York, NY INTRODUCTION AND OBJECTIVES: Classic diabetic cystopathy is described as decreased bladder sensation, increased bladder capacity, and impaired detrusor contractility. Urodynamics (UDS) in patients with diabetes mellitus (DM) have not been well studied. We wanted to characterize urodynamic findings in patients with DM and lower urinary tract symptoms (LUTS) from a contemporary database. METHODS: A multi-center UDS database (1997-2009) of 3663 records was retrospectively analyzed for patients with DM and LUTS. UDS were performed according to International Continence Society standards. Statistical analysis used Fisher’s exact and Mann-Whitney U tests. RESULTS: 257 patients were identified: 173 men and 84 women. 74 patients had insulin dependent DM (IDDM) and 183 patients non-insulin dependent DM (NIDDM). Mean age was 69.6⫾11.5 years. In women, presenting complaints were frequency in 47 (56%), urgency in 45 (54%), and stress incontinence (SUI) in 37 (44%). Presenting symptoms in men were frequency in 99 (57%), nocturia in 83 (48%), and urgency in 78 (45%). 9 women (11%) and 40 men (23%) were in urinary retention. In women, mean bladder capacity was 378 ⫾191 mL, volume at first sensation 166 ⫾105 mL, maximum flow rate (Qmax) 17 ⫾13 mL/s, and post-void residual (PVR) 46 ⫾109 mL. Mean bladder capacity in men was 424 ⫾242 mL, first sensation volume 194 ⫾ 139 mL, Qmax 12 ⫾16 mL, and PVR 47 ⫾112 mL. Mean International Prostate Symptom Score (IPSS) in men was 15.6 ⫾8.9. Prevalence of SUI in women with IDDM was 37% (n⫽13) and 55% (n⫽27) in those with NIDDM (p⫽0.08). No significant differences were seen between patients with IDDM and NIDDM in Qmax, PVR, and volume at first sensation. Bladder capacity was higher in patients with IDDM (445 ⫾210 mL versus 394 ⫾ 232mL, p⫽0.035). CONCLUSIONS: This contemporary series of patients with DM and LUTS does not demonstrate classic findings of diabetic cystopathy in most patients. The most common urodynamic diagnosis was DO. Other common diagnoses, BOO in men and SUI in women, do not differ from expected diagnoses in patients without DM. The only significant difference between patients with IDDM and NIDDM was increased bladder capacity in IDDM patients. This study is also the first to analyze urodynamic findings between men and women with DM and LUTS and may help provide clinical insight into their disease management. Table 1. Urodynamic Diagnoses in Patients with DM and LUTS Urodynamic Diagnosis Men (Nⴝ173) Women (Nⴝ84) Detrusor Overactivity (DO) 122 (68%) 51 (61%) Bladder Outlet Obstruction (BOO)
118 (66%)
10 (12%)
DO ⫹ BOO
85 (48%)
SUI
11 (6%)
10 (48%)
Impaired Detrusor Contractility (IDC)
40 (22%)
26 (31%)
SUI ⫹ IDC Impaired Bladder Sensation Acontractile Detrusor
8 (9.5%)
0 (0%)
14 (17%)
32 (18%)
18 (21%)
3 (2%)
2 (2%)
Source of Funding: None
1621 EXERCISE PREVENTS BLADDER DYSFUNCTION IN THE TYPE 2 DIABETIC MOUSE MODEL Manasi Vadhavkar, Lynn Stothers*, Ismail Laher, Vancouver, Canada INTRODUCTION AND OBJECTIVES: Type 2 diabetes accounts for more than 90% of diabetes mellitus. Detrusor dysfunction is a frequent complication of diabetes and can lead to a variety of lower
urinary tract symptoms (LUTS). Exercise is the initial recommended management strategy in many diabetics and has been shown to prevent or reduce muscle dysfunction in other areas of the body; but its effect on prevention of detrusor dysfunction is unknown. The objective of this study was to determine if the introduction of moderate exercise early in the onset of type 2 diabetes would prevent bladder dysfunction and reduce voiding frequency in the db/db mouse, a frequently used animal model of type 2 diabetes. METHODS: A randomised trial of 24 db/db female mice (BKS. Cg-m⫹/⫹Leprdb/ J strain) and their age matched wild type controls (WT) were used. Mice were equally divided into sedentary and exercise groups. Exercise consisted of one hour daily treadmill drills for 8 weeks at a speed of 5.2 meters/min. Ambulatory urodynamic protocols using suprapubic cystostomy were performed with water infusion to observe for overactivity, functional volume and pressure flow in all cohorts. Pad voiding pattern tests, contractile strength and reactivity of isolated detrusor strips in WT and db/db mice, in both sedentary and exercise groups were compared pharmacologically. RESULTS: Diabetes increased the frequency of voiding, bladder capacity and residual volume. Exercise decreased voiding frequency in db/db mice where the voiding frequency was 5.8 ⫾ 0.5 (db/db exercise) vs.10.8 ⫾ 1.1 (db/db control) (t-test, P ⬍ 0.001). In cystometric analysis, the bladder capacity of db/db sedentary mice was 0.27 ⫾ 0.05 ml compared to 0.14 ⫾ 0.02 ml in the db/db exercise group (t- test, P ⬍ 0.05). Micturition pressure was higher in the db/db sedentary mice (30.69 ⫾ 1.51 cm H2O vs. 25.61 ⫾ 1.13 cm H2O after exercise, t- test, P ⬍ 0.05). Isolated strips of bladder muscle from sedentary db/db mice were more responsive to carbachol than strips from db/db exercise mice. This moderate level of exercise did not alter the body weight or blood glucose levels of db/db mice. CONCLUSIONS: Moderate routine exercise resulted in detrusor function in type 2 diabetic mice statically comparable to non diabetic controls. Reduced voiding frequency and improved urodynamic parameters including reduction in overactivity and improved emptying were observed benefits; complications of which were statistically higher in the sedentary diabetic group. These findings suggest a potentially preventable component to diabetic detrusor dysfunction which could form the foundation for human studies. Source of Funding: None
1622 IS THE URETHRAL SHINCTER PRESSURE A BETTER PARAMETER TO EVALUATE THE MOST EFFECTIVE ELECTRODE POSITION FOR SACRAL NEUROMODULATION? AN ANIMAL STUDY Andreas Bannowsky*, Osnabru¨ck, Germany; Shuji Sugimoto, Tokyo, Japan; Georg Bo¨hler, Barbara Klein, Klaus-Peter Ju¨nemann, Kiel, Germany INTRODUCTION AND OBJECTIVES: The crucial parameter for a successful result of sacral neuromodulation (SNM) seems to be the position of the electrodes. Few parameters are used to indicate the correct electrode position: 1. contraction of the anal sphincter and 2. a plantar flexion of the great toe. We tried to identify a more sensitive parameter for optimal electrode positioning. METHODS: In animal models (Go¨ttinger Minipig (n⫽4) and rabbit (n⫽6)), we performed a peripheral nerve evaluation (PNE test) with recording of the intravesical and intrarectal pressure, as well as the pressures of the urethral and the anal sphincter. Electrodes were applied bilaterally to the foramina S1-S4 and SNM was performed at 5 different electrode positions, which differed in the depth of infiltration (monophasic rectangular signal, 210s, 21Hz, 0.5V). Afterwards the electrodes were placed to the position with highest urethral sphincter response. At this level a stimulation was performed for one minute with measuring the urine flow and micturition volume. RESULTS: The electrode position showing the max. stimulation response of the urethral sphincter differed significantly from that with the max. anal sphincter response (p⬍0.05). Stimulation at the elec-
THE JOURNAL OF UROLOGY姞
Vol. 183, No. 4, Supplement, Tuesday, June 1, 2010
1620 URODYNAMIC FINDINGS IN PATIENTS WITH DIABETES MELLITUS AND LOWER URINARY TRACT SYMPTOMS Doreen E. Chung*, Bobby B. Najari, Richard K. Lee, Steven A. Kaplan, Alexis E. Te, New York, NY INTRODUCTION AND OBJECTIVES: Classic diabetic cystopathy is described as decreased bladder sensation, increased bladder capacity, and impaired detrusor contractility. Urodynamics (UDS) in patients with diabetes mellitus (DM) have not been well studied. We wanted to characterize urodynamic findings in patients with DM and lower urinary tract symptoms (LUTS) from a contemporary database. METHODS: A multi-center UDS database (1997-2009) of 3663 records was retrospectively analyzed for patients with DM and LUTS. UDS were performed according to International Continence Society standards. Statistical analysis used Fisher’s exact and Mann-Whitney U tests. RESULTS: 257 patients were identified: 173 men and 84 women. 74 patients had insulin dependent DM (IDDM) and 183 patients non-insulin dependent DM (NIDDM). Mean age was 69.6⫾11.5 years. In women, presenting complaints were frequency in 47 (56%), urgency in 45 (54%), and stress incontinence (SUI) in 37 (44%). Presenting symptoms in men were frequency in 99 (57%), nocturia in 83 (48%), and urgency in 78 (45%). 9 women (11%) and 40 men (23%) were in urinary retention. In women, mean bladder capacity was 378 ⫾191 mL, volume at first sensation 166 ⫾105 mL, maximum flow rate (Qmax) 17 ⫾13 mL/s, and post-void residual (PVR) 46 ⫾109 mL. Mean bladder capacity in men was 424 ⫾242 mL, first sensation volume 194 ⫾ 139 mL, Qmax 12 ⫾16 mL, and PVR 47 ⫾112 mL. Mean International Prostate Symptom Score (IPSS) in men was 15.6 ⫾8.9. Prevalence of SUI in women with IDDM was 37% (n⫽13) and 55% (n⫽27) in those with NIDDM (p⫽0.08). No significant differences were seen between patients with IDDM and NIDDM in Qmax, PVR, and volume at first sensation. Bladder capacity was higher in patients with IDDM (445 ⫾210 mL versus 394 ⫾ 232mL, p⫽0.035). CONCLUSIONS: This contemporary series of patients with DM and LUTS does not demonstrate classic findings of diabetic cystopathy in most patients. The most common urodynamic diagnosis was DO. Other common diagnoses, BOO in men and SUI in women, do not differ from expected diagnoses in patients without DM. The only significant difference between patients with IDDM and NIDDM was increased bladder capacity in IDDM patients. This study is also the first to analyze urodynamic findings between men and women with DM and LUTS and may help provide clinical insight into their disease management. Table 1. Urodynamic Diagnoses in Patients with DM and LUTS Urodynamic Diagnosis Men (Nⴝ173) Women (Nⴝ84) Detrusor Overactivity (DO) 122 (68%) 51 (61%) Bladder Outlet Obstruction (BOO)
118 (66%)
10 (12%)
DO ⫹ BOO
85 (48%)
SUI
11 (6%)
10 (48%)
Impaired Detrusor Contractility (IDC)
40 (22%)
26 (31%)
SUI ⫹ IDC Impaired Bladder Sensation Acontractile Detrusor
8 (9.5%)
0 (0%)
14 (17%)
32 (18%)
18 (21%)
3 (2%)
2 (2%)
Source of Funding: None
1621 EXERCISE PREVENTS BLADDER DYSFUNCTION IN THE TYPE 2 DIABETIC MOUSE MODEL Manasi Vadhavkar, Lynn Stothers*, Ismail Laher, Vancouver, Canada INTRODUCTION AND OBJECTIVES: Type 2 diabetes accounts for more than 90% of diabetes mellitus. Detrusor dysfunction is a frequent complication of diabetes and can lead to a variety of lower
urinary tract symptoms (LUTS). Exercise is the initial recommended management strategy in many diabetics and has been shown to prevent or reduce muscle dysfunction in other areas of the body; but its effect on prevention of detrusor dysfunction is unknown. The objective of this study was to determine if the introduction of moderate exercise early in the onset of type 2 diabetes would prevent bladder dysfunction and reduce voiding frequency in the db/db mouse, a frequently used animal model of type 2 diabetes. METHODS: A randomised trial of 24 db/db female mice (BKS. Cg-m⫹/⫹Leprdb/ J strain) and their age matched wild type controls (WT) were used. Mice were equally divided into sedentary and exercise groups. Exercise consisted of one hour daily treadmill drills for 8 weeks at a speed of 5.2 meters/min. Ambulatory urodynamic protocols using suprapubic cystostomy were performed with water infusion to observe for overactivity, functional volume and pressure flow in all cohorts. Pad voiding pattern tests, contractile strength and reactivity of isolated detrusor strips in WT and db/db mice, in both sedentary and exercise groups were compared pharmacologically. RESULTS: Diabetes increased the frequency of voiding, bladder capacity and residual volume. Exercise decreased voiding frequency in db/db mice where the voiding frequency was 5.8 ⫾ 0.5 (db/db exercise) vs.10.8 ⫾ 1.1 (db/db control) (t-test, P ⬍ 0.001). In cystometric analysis, the bladder capacity of db/db sedentary mice was 0.27 ⫾ 0.05 ml compared to 0.14 ⫾ 0.02 ml in the db/db exercise group (t- test, P ⬍ 0.05). Micturition pressure was higher in the db/db sedentary mice (30.69 ⫾ 1.51 cm H2O vs. 25.61 ⫾ 1.13 cm H2O after exercise, t- test, P ⬍ 0.05). Isolated strips of bladder muscle from sedentary db/db mice were more responsive to carbachol than strips from db/db exercise mice. This moderate level of exercise did not alter the body weight or blood glucose levels of db/db mice. CONCLUSIONS: Moderate routine exercise resulted in detrusor function in type 2 diabetic mice statically comparable to non diabetic controls. Reduced voiding frequency and improved urodynamic parameters including reduction in overactivity and improved emptying were observed benefits; complications of which were statistically higher in the sedentary diabetic group. These findings suggest a potentially preventable component to diabetic detrusor dysfunction which could form the foundation for human studies. Source of Funding: None
1622 IS THE URETHRAL SHINCTER PRESSURE A BETTER PARAMETER TO EVALUATE THE MOST EFFECTIVE ELECTRODE POSITION FOR SACRAL NEUROMODULATION? AN ANIMAL STUDY Andreas Bannowsky*, Osnabru¨ck, Germany; Shuji Sugimoto, Tokyo, Japan; Georg Bo¨hler, Barbara Klein, Klaus-Peter Ju¨nemann, Kiel, Germany INTRODUCTION AND OBJECTIVES: The crucial parameter for a successful result of sacral neuromodulation (SNM) seems to be the position of the electrodes. Few parameters are used to indicate the correct electrode position: 1. contraction of the anal sphincter and 2. a plantar flexion of the great toe. We tried to identify a more sensitive parameter for optimal electrode positioning. METHODS: In animal models (Go¨ttinger Minipig (n⫽4) and rabbit (n⫽6)), we performed a peripheral nerve evaluation (PNE test) with recording of the intravesical and intrarectal pressure, as well as the pressures of the urethral and the anal sphincter. Electrodes were applied bilaterally to the foramina S1-S4 and SNM was performed at 5 different electrode positions, which differed in the depth of infiltration (monophasic rectangular signal, 210s, 21Hz, 0.5V). Afterwards the electrodes were placed to the position with highest urethral sphincter response. At this level a stimulation was performed for one minute with measuring the urine flow and micturition volume. RESULTS: The electrode position showing the max. stimulation response of the urethral sphincter differed significantly from that with the max. anal sphincter response (p⬍0.05). Stimulation at the elec-