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Introduction: To better understand the role of the brain in urgency urinary incontinence (UUI), we used onabotulinumtoxin A (BoNTA) as a probe to evaluate changes in the brain's response to urgency in successful and unsuccessful treatment. Because BoNTA acts peripherally, brain changes observed should represent a reaction to changes in bladder function caused by BoNTA, or changes in the brain's compensatory mechanisms, rather than a direct effect of BoNTA on the brain. Methods: We recruited 20 women aged over 60 years with nonneurogenic UUI who were to undergo treatment with onabotulinum A toxin injected intravesically. We performed a baseline evaluation which included a 3‐day bladder diary and functional magnetic resonance imaging with an urgency provocation task; we repeated this evaluation 6 weeks posttreatment. We performed an analysis of variance on a priori selected regions of interest and post hoc voxel‐wise analysis on responders and nonresponders to treatment. Results: We found a significant interaction in the right insula [F(1,18) = 5.5, p = 0.031]; activity was different during urgency provocation in responders and non‐responders to therapy, before and after therapy. The supramarginal gyrus (SMG) and inferior frontal gyrus (IFG) also displayed significant interactions (p < 0.005). Activity in the periaqueductal gray and prefrontal cortex was correlated with number of leakage episodes (p < 0.05). Conclusion: The changes seen in the brain control mechanism after therapy likely reflect reduced bladder sensation caused by BoNTA's peripheral action. We ascribe the SMG and IFG changes to a coping mechanism for urgency which is reduced in those who respond well to treatment. [ABSTRACT FROM AUTHOR]

Introduction: Situational triggers for urinary urgency and incontinence (UUI) such as "latchkey incontinence" and running water are often reported clinically, but no current clinical tools exist to directly address symptoms of UUI provoked by environmental stimuli. Previously we have shown that urgency and leakage can be reproduced during urodynamic studies with exposure to personal urgency‐related images. Here we investigate the neural signatures associated with such situational triggers to inform potential therapies for reducing reactivity to these personal urgency‐related cues among women with situational UUI. Method: We recruited 23 women with situational UUI who took photographs of their personal "urgency trigger" and "safe" situations and were exposed to them in a magnetic resonance imaging (MRI) scanner. We identified brain areas that were more active during urgency versus safe image exposure. Results: We found that, during urgency image exposure, main components of the attention network and decision‐related processes, the middle and medial frontal gyri, were more active (p < 0.01). In addition, areas well known to be involved in the continence mechanism, such as the cingulate and parahippocampal areas, were also more active during urgency image exposure. Conclusion: Exposure to personal situational urgency images activated different areas of the brain compared with safe environments, highlighting the complex brain mechanisms that provoke real‐world urgency. Using brain and behavioral‐based therapies which target the attentional areas identified here and extinguish cue reactivity might reduce symptom burden in this subset of UUI sufferers. [ABSTRACT FROM AUTHOR]

Introduction: The brain's role in bladder control has become an important area of study in the last 15 years. Typically, the brain's role in urinary urgency has been studied by repeated infusion and withdrawal of fluid, per catheter, to provoke urgency sensation during a whole brain magnetic resonance imaging (MRI) scan. Since this technique generally requires a large group size, we tested a more intense infusion‐withdrawal protocol in an attempt to improve signal to noise ratio and repeatability of the signal which would, in turn, allow us to further probe subtypes of urgency urinary incontinence. Methods: A total of 12 women over the age of 60 were recruited to test a new "intense" infusion withdrawal protocol. They underwent this new protocol during a functional brain MRI scan. The primary outcome was comparison of activity within the insula, medial pre‐frontal cortex and dorsal anterior cingulate cortex/supplementary motor area (dACC/SMA). Immediate test‐retest repeatability was measured using intraclass correlation. Secondary exploratory evaluation of differences in the whole brain between protocols was conducted. Results: There was no significant difference in signal in any of the a priori regions of interest between protocols. Test‐retest repeatability in the new protocol was poor compared to the original protocol, and variability was higher. Three participants were not able to tolerate the "intense" protocol. Conclusion: The small improvement in signal to noise ratio of the new protocol was not sufficient to overcome the poorly tolerated intense filling protocol. [ABSTRACT FROM AUTHOR]

Introduction: Patients with lower urinary tract symptoms often report urgency and incontinence episodes which are triggered by environmental scenarios, for example, "latch‐key incontinence." To better understand the extent of this phenomenon, and how best to reduce its impact, we tested ways to recreate these situational cues in a controlled environment and obtain cue reactivity measures. Methods: We developed a standardized set of urgency cue scenarios from interviews with sufferers of situational urgency urinary incontinence (UUI), personalized urgency, and safe cue sets consisting of photographs of specific locations, and measurements of cue reactivity during computer‐based presentation and urodynamic monitoring. Results: Common urgency and safe cues were identified for the standardized cue set. Exposure to these standardized cues elicited change in bladder sensation in 7 of 12 participants. Participants created personalized cue sets with photographs depicting their own urgency triggering scenarios; exposure to personalized cue photos elicited change in sensation in 11 of 12 participants. In addition, personalized cues elicited measurable detrusor overactivity and leakage during urodynamic monitoring. Safe cues reduced bladder sensation in five participants. Conclusion: We developed a computer‐based means of displaying cue photos which elicited cue reactivity from women suffering from situational urgency incontinence. Cue reactivity was increased by personalizing photos of cue scenarios and obtaining physiological measures from urodynamics. We have developed an appropriate way to test cue reactivity in women with situational UUI. [ABSTRACT FROM AUTHOR]

Background: The brain's role in continence is critical but poorly understood. Although regions activated during bladder stimulation have been identified, little is known about the interaction between regions. In this secondary analysis we evaluate resting state and effective connectivity in older women treated for urgency urinary incontinence (UUI). Method: 54 women ≥60 years old with UUI and 10 continent women underwent fMRI scanning during provocation of urinary urgency, both before and after therapy. Response was defined by >50% reduction in leaks on bladder diary. Regions of interest (RoIs) were selected a priori: right insula, medial prefrontal cortex, and dorsal anterior cingulate cortex. Generalized psycho‐physiological interaction (gPPI) was used to calculate "effective connectivity" between RoIs during urgency. We performed a one‐way ANOVA pre‐treatment between groups (continent/responders/non‐responders), as well as a two‐way mixed ANOVA between group and time (responders/non‐responders; pre‐/post‐therapy) using false discovery rate (FDR) correction. Principal component analysis was used to assess the variance within RoIs. Exploratory voxel‐wise connectivity analyses were conducted between each RoI and the rest of the brain. Results: RoI‐RoI connectivity analysis showed connectivity differences between controls, responders, and non‐responders, although statistical significance was lost after extensive correction. Principal component analysis confirmed appropriate RoI selection. Voxel‐wise analyses showed that connectivity in responders became more like that of controls after therapy (cluster‐wise correction P < 0.05). In non‐responders, no consistent changes were seen. Conclusion: These data support the postulate that responders and non‐responders to therapy may represent different subsets of UUI, one with more of a central etiology, and one without. [ABSTRACT FROM AUTHOR]

Aims: Urgency urinary incontinence (UUI) is a major problem for seniors. The underlying mechanisms of disease and therapy are unknown. We sought structural brain abnormalities that might underlie the functional differences previously observed by functional Magnetic Resonance Imaging in UUI patients versus controls, or among UUI responders versus non‐responders to therapy—and thereby reveal potential disease mechanisms and therapeutic targets. Methods: Secondary study of a trial of biofeedback‐assisted pelvic floor muscle training (BFB) in 60 women (>60 yrs) with UUI, plus 11 age‐matched continent controls. Brain structural abnormalities were investigated using: (1) white‐matter hyperintensities (WMH); (2) diffusion tensor imaging (DTI) to reveal white‐matter pathways with impaired integrity; and (3) voxel‐based morphometry (VBM) to show regions of atrophy or hypertrophy. Results: WMH burden was greater in UUI patients than controls (globally and in superior longitudinal fasciculus and cingulum), suggesting a possible causal connection. WMH burden was unexpectedly greater in responders than non‐responders to BFB, and appeared to increase in non‐responders but not in responders. DTI revealed even worse integrity of the cingulum than was apparent by WMH. VBM showed parahippocampal atrophy in UUI. Conclusions: Many women with UUI have white‐matter damage that interferes with pathways critical to bladder control; they can be taught by techniques like BFB to exert stronger control over the bladder. For others, in whom abnormalities of key brain areas are less marked, UUI's cause may reside elsewhere, and therapy targeting these brain centers may be less effective than therapy targeting the bladder or other brain centers. [ABSTRACT FROM AUTHOR]

Objective To assess short-term repeatability of an fMRI protocol widely used to assess brain control of the bladder. fMRI offers the potential to discern incontinence phenotypes as well as the mechanisms mediating therapeutic response. If so, this could enable more targeted efforts to enhance therapy. Such data, however, require excellent test-retest repeatability. Methods Fifty-nine older women (age ≥60 years) with urgency incontinence underwent two fMRI scans within 5-10 min with a concurrent bladder infusion/withdrawal protocol. Activity in three brain regions relevant to bladder control was compared using paired t tests and intra-class correlation. Results There were no statistically significant differences in brain activity between the two consecutive scans in the regions of interest. Intra-class correlation was 0.19 in the right insula, 0.32 in the dorsal anterior cingulate cortex/supplementary motor area, and 0.44 in the medial pre-frontal cortex. Such correlations are considered fair or poor, but are comparable to those from studies of other repeated fMRI tasks. Conclusions This is the first evaluation of the repeatability of a bladder fMRI protocol. The technique used provides a framework for comparing different fMRI protocols applied to brain-bladder research. Despite universal patient response to the stimulus, brain response had limited repeatability within individuals. Improvement of the investigational protocol should magnify brain response and reduce variability. These results suggest that although analysis of fMRI data among groups of subjects yields valuable insight into bladder control, fMRI is not yet appropriate for evaluation of the brain's role in continence on an individual level. [ABSTRACT FROM AUTHOR]

These guidelines provide benchmarks for the performance of urodynamic equipment, and have been developed by the International Continence Society to assist purchasing decisions, design requirements, and performance checks. The guidelines suggest ranges of specification for uroflowmetry, volume, pressure, and EMG measurement, along with recommendations for user interfaces and performance tests. Factors affecting measurement relating to the different technologies used are also described. Summary tables of essential and desirable features are included for ease of reference. It is emphasized that these guidelines can only contribute to good urodynamics if equipment is used properly, in accordance with good practice. Neurourol. Urodynam. 33:370-379, 2014. © 2014 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Aims To identify, in subjects with overactive bladder (OAB), differences in brain activity between those who maintained and those who lost bladder control during functional magnetic resonance imaging (fMRI) of the brain with simultaneous urodynamics. Methods Secondary analysis of a cohort of older women (aged >60) with proven urgency urinary incontinence, who, in the scanner, either developed detrusor overactivity and incontinence (the 'DO group') or did not (the 'no DO' group). A priori hypothesis: during urgency provoked by bladder filling, without DO, activity in regions related to continence control is diminished in the DO group; specifically (1a) less activation in supplementary motor area (SMA) and (1b) less deactivation in prefrontal cortex (PFC) and parahippocampal complex (PH). We also explored phenotypic (clinical and urodynamic) differences between the groups. Results During urgency preceding DO, the DO group showed stronger activation in SMA and adjacent regions (hypothesis 1a rejected), and less deactivation in PH but no significant difference in PFC (hypothesis 1b partially accepted). These subjects were older, with more changes in brain's white matter, decreased tolerance of bladder filling and greater burden of incontinence. Conclusions (1) In older women with OAB, brain activity in the SMA is greater among those with more easily elicitable DO, suggesting a compensatory response to failure of control elsewhere. (2) OAB is heterogeneous; one possible phenotype shows severe functional impairment attributable partly to age-related white matter changes. (3) Functional brain imaging coupled with urodynamics may provide CNS markers of impaired continence control in subjects with OAB. Neurourol. Urodynam. 31:652-658, 2012. © 2012 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Purpose We developed a prototype device using an automatically controlled inflatable penile cuff to measure bladder voiding pressure continuously and non-invasively in men. The purpose of this study was to validate the pressure measurements made by this device by comparison to those during simultaneous invasive PFS. Methods A device was developed to automatically modulate flow rate by controlling pressure in a penile cuff. Men undergoing conventional urodynamics studies were recruited to have an additional fill-void cycle whilst using the new device. We report on 40 men using a standardized protocol. Pressure measured by this device was compared with simultaneous vesical pressure by evaluating maximum pressure during voiding, and calculating the root mean square (RMS) difference between pcuff and pves. Results We recruited 80 men of whom 18 were excluded, 22 were involved in initial development phase and 40 in the standard protocol. Mean (SD) difference between maxima of pcuff and pves (1.3 (15.6) cmH2O) was not significant. In 20 (50%) men, agreement between pcuff and pves throughout the void was moderate or good (RMS difference <20 cmH2O). Causes of unsuccessful measurements were identified. Conclusions Although a prototype device, this technique appears to be promising for continuous non-invasive bladder pressure measurement. From the results of this study a number of improvements have been recommended and implemented. The next generation of this technique will allow assessment of clinical application. Neurourol. Urodynam. 31:557-563, 2012. © 2011 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]