Comment : This paper was accepted to be presented by De Nguyen, M.D., F.A.C.P. at the Annual Meeting of the Ohio Academy of Science at the University of Toledo, Ohio on April 12,2008.
Bladder Dysfunction
Annual Meeting
of
OHIO ACADEMY OF SCIENCE
University of Toledo, Ohio
April 12, 2008
DE NGUYEN, M.D., F.A.C.P
ORLANDO, FLORIDA 32817
INTRODUCTION
The purpose of this paper is to present the possibility of the Bladder Dysfunction. Traditionally, the urinary frequency, urgency, urge incontinence in men of 40 years or older suggest the possibility of a benign prostatic hypertrophy or cancer. However, Patrict C. Walsh wrote in his Editorial in the New England Journal of Medicine (08-09-1996) : "There is another condition in which men with small prostate have the same symptoms".
We are going to discuss the new entity other than benign prostatic hypertrophy or cancer.
Case presentation:
AG is a 50 years old White Male who presents to our clinic with hypertension and irritative symptoms of a possible beningn prostatic hypertrophy for the first time . His symptoms consisted of urinary frequency, urgency, and urge incontinence.
Past Hisstory:
He denies coronary artery disease, diabetes mellitus, disorders of autonomic nervous system or periperal arterial disease.
Physical examination:
Hight= 5'7", Weight= 65 lbs., BP= 145/96 mmHg, Pulse =78, Respiration= 18, T= 98.6.
His physical examination was within normal limits. His prostate examination was also normal.
Laboratory:
He had a normal comprehensive panel and urine analysis. His urine culture was sterile. His PSA was 2.8 ng/ml.
Impression:
1- Hypertension.
2-Possible benign prostatic hypertrophy.
Treatment Plan:
He was prescribed Nifedipine XL 30 mg P.O. qAM. A urology consultation to rule out benign prostatic hypertrophy or prostate cancer was sent. He was instructed to return in a week for follow up.
Follow up Visit:
On his return visit, his BP = 120/80 mmHg. All urinary symptoms were under good control. The urologic work up showed no evidence of benign prostatic hypertrophy or cancer. We follow this case for up to four years. His blood pressure and urinary symptoms were well controlled. His PSA levels were below 4 ng/ml.
These data allowed us to have the hypothesis of Bladder Dysfunction.
HYPOTHESIS
Our hypothesis was based on the clinical and experimental data :
A- Clinical Data
1- The autopsy data of all the 18 years old GIs who died in the Korea and Vietnam Wars showed early fatty streaks of cholesterol plaques in their arterial walls. But the myocardial infarction occurs only in 40 years or older American men. These data suggested that the atherosclerosis took two or three decades later to develop and cause diseases.
2- All these patients did not have these urinary symptoms when they were in their younger age. The prevalence of these symptoms increases with age in both men and women.
3- Dr. Cathryn Glazener tracked 4.000 women in 12 years : Over half of these women reported urinary incontinence.
B- Experimental Data :
1- Zhao, Bilgen and Levin in their "Effect of Anoxia on in vitro Bladder Function" showed anoxia inhibited the ability of the bladder to empty and virtually eliminated the the tonic component of the response to field stimulation and Bethanechol administration.
2- Reed Detar showed that hypoxia depressed vascular smooth muscle contractions.
These clinical and experimental data support the fact that the observed urinary symptoms are due to the bladder dysfunction. In fact, stenotic arteries generate an metabolic acidosis. When the cellular pH drops severely, it causes erratic and uncontrolled muscle contractions which may overcome the control of the central nervous system and produce explosive and unpredictable symptoms.
The effective treatment of Mr. AG's urinary symptoms with the vasodilator Nifedipine is the proof of treating his bladder dysfunction. The excellent response to Nifedipine strongly support our hypothesis of hypoxia secondary to age-related atherosclerosis in men and women, which cause explosive and unpredictable symptoms. In effect, the vasodilators release the hypoxia. The metabolic acidosis dissipates. The normal function of the bladder returns
Discussion:
1- Urinary frequency, urgency, and urge incontinence are common in many diseases. Among the most common entities are drugs, prostatic hypertrophy and cancer. Drugs are ruled out by history.
2- The prostatic hypertrophy and cancer are ruled out by digital examination of the prostate, sonography, and needle biopsy.
3- There was no evidence of arterial disease by clinical manifestations in this patient.
4- The patient did not have diabetes mellitus, so the diabetic neuropathy was ruled out.
5- The patient did not have signs and symptoms of altered sweating (hyperhydrosis or hypohydrosis), orthostatic hypotention or impotence to consider the possibility of disorders of autonomic nervous system. In addition, the vasodilators have no role in the treatment of these disorders( patients with these disorders may have urinary frequency, hesitancy or incontinence)
6- We have to discuss here the Overactive Bladder Syndrome (OBS) with more details. This syndrome has the same symptoms than bladder dysfunction (urinary frequency, urgency, urge incontinence and nocturia). The overactive bladder contracts suddenly without you having control and when the bladder is not full. The medical science could not find any cause of this syndrome. Overactive bladder syndrome is sometimes called an Irritable Bladder or Detrusor Instability. The recommended treatment consists of some general lifestyle measures, bladder training, pelvic floor exercises and medications.
The medication includes the class of drugs called antimuscarinics (or anticholinergics) which are oxybutynin, tolterodine, trospium chloride, propiverine, and solifenacine. These drugs work by blocking certain nerve impulses to the bladder, which relaxes the bladder muscle and so increases the bladder capacity. Medication improves symptoms in some cases, but not all. The side-effects are quite common : dry mouth, dry eyes, constipation, and blurred vision.
Other treatment includes surgery (sacral nerve stimulation, augmentation cystoplasty, urinary diversion. The treatment with botulinum toxin A is not approved by Food and Drugs Administration.
In overactive bladder syndrome, all the patients did not have it when they were much younger . They start to have it when they are 40 years of age or older. We see a clearly striking similarity with myocardial infarction (heart attack). In our bladder dysfunction, we have formulated a theoretical cause of the disease. We postulated the cause which is the hypoxia of the bladder by atherosclerosis and treat the cause directly with vasodilator agents, which re-establish the blood flow to the bladder and stop and/or alleviate the metabolic acidosis, the source of explosive and unpredictable muscle contractions. The response to the vasodilator agents was excellent with almost no troublesome side-effects like thoses of the anticholinergics. The excellent response to our treatment was the convincing experimental proof that our postulated cause was correct. For now, the cause of bladder dysfunction is not yet scientifically proven by multiple studies with larger sample sizes, but it has been practically proven by treatment with vasodilator medications such as Nifedipine.
CONCLUSION:
1- The Bladder Dysfunction causes symptoms in both men and women in advanced age (45 or older).
2- Benign prostatic hypertrophy and cancer must be ruled out before making the diagnosis of Bladder Dysfunction.
3- Multiple studies with large sample sizes, angiographic investigation of the vesical arteries, and measurement of urine flow pre- and post-treatment with vasodilator agents will support our hypothesis.
4- Bladder dysfunction is an age-related malfunction of the bladder by hypoxia secondary to atherosclerosis.
Notice:
This is a Free Medical Science Information to serve the humanity. If you like the treatment of Bladder Dysfunction, consult your doctor : Ask him or her if this treatment is good for your problem?.
Bladder Dysfunction
Annual Meeting
of
OHIO ACADEMY OF SCIENCE
University of Toledo, Ohio
April 12, 2008
DE NGUYEN, M.D., F.A.C.P
ORLANDO, FLORIDA 32817
INTRODUCTION
The purpose of this paper is to present the possibility of the Bladder Dysfunction. Traditionally, the urinary frequency, urgency, urge incontinence in men of 40 years or older suggest the possibility of a benign prostatic hypertrophy or cancer. However, Patrict C. Walsh wrote in his Editorial in the New England Journal of Medicine (08-09-1996) : "There is another condition in which men with small prostate have the same symptoms".
We are going to discuss the new entity other than benign prostatic hypertrophy or cancer.
Case presentation:
AG is a 50 years old White Male who presents to our clinic with hypertension and irritative symptoms of a possible beningn prostatic hypertrophy for the first time . His symptoms consisted of urinary frequency, urgency, and urge incontinence.
Past Hisstory:
He denies coronary artery disease, diabetes mellitus, disorders of autonomic nervous system or periperal arterial disease.
Physical examination:
Hight= 5'7", Weight= 65 lbs., BP= 145/96 mmHg, Pulse =78, Respiration= 18, T= 98.6.
His physical examination was within normal limits. His prostate examination was also normal.
Laboratory:
He had a normal comprehensive panel and urine analysis. His urine culture was sterile. His PSA was 2.8 ng/ml.
Impression:
1- Hypertension.
2-Possible benign prostatic hypertrophy.
Treatment Plan:
He was prescribed Nifedipine XL 30 mg P.O. qAM. A urology consultation to rule out benign prostatic hypertrophy or prostate cancer was sent. He was instructed to return in a week for follow up.
Follow up Visit:
On his return visit, his BP = 120/80 mmHg. All urinary symptoms were under good control. The urologic work up showed no evidence of benign prostatic hypertrophy or cancer. We follow this case for up to four years. His blood pressure and urinary symptoms were well controlled. His PSA levels were below 4 ng/ml.
These data allowed us to have the hypothesis of Bladder Dysfunction.
HYPOTHESIS
Our hypothesis was based on the clinical and experimental data :
A- Clinical Data
1- The autopsy data of all the 18 years old GIs who died in the Korea and Vietnam Wars showed early fatty streaks of cholesterol plaques in their arterial walls. But the myocardial infarction occurs only in 40 years or older American men. These data suggested that the atherosclerosis took two or three decades later to develop and cause diseases.
2- All these patients did not have these urinary symptoms when they were in their younger age. The prevalence of these symptoms increases with age in both men and women.
3- Dr. Cathryn Glazener tracked 4.000 women in 12 years : Over half of these women reported urinary incontinence.
B- Experimental Data :
1- Zhao, Bilgen and Levin in their "Effect of Anoxia on in vitro Bladder Function" showed anoxia inhibited the ability of the bladder to empty and virtually eliminated the the tonic component of the response to field stimulation and Bethanechol administration.
2- Reed Detar showed that hypoxia depressed vascular smooth muscle contractions.
These clinical and experimental data support the fact that the observed urinary symptoms are due to the bladder dysfunction. In fact, stenotic arteries generate an metabolic acidosis. When the cellular pH drops severely, it causes erratic and uncontrolled muscle contractions which may overcome the control of the central nervous system and produce explosive and unpredictable symptoms.
The effective treatment of Mr. AG's urinary symptoms with the vasodilator Nifedipine is the proof of treating his bladder dysfunction. The excellent response to Nifedipine strongly support our hypothesis of hypoxia secondary to age-related atherosclerosis in men and women, which cause explosive and unpredictable symptoms. In effect, the vasodilators release the hypoxia. The metabolic acidosis dissipates. The normal function of the bladder returns
Discussion:
1- Urinary frequency, urgency, and urge incontinence are common in many diseases. Among the most common entities are drugs, prostatic hypertrophy and cancer. Drugs are ruled out by history.
2- The prostatic hypertrophy and cancer are ruled out by digital examination of the prostate, sonography, and needle biopsy.
3- There was no evidence of arterial disease by clinical manifestations in this patient.
4- The patient did not have diabetes mellitus, so the diabetic neuropathy was ruled out.
5- The patient did not have signs and symptoms of altered sweating (hyperhydrosis or hypohydrosis), orthostatic hypotention or impotence to consider the possibility of disorders of autonomic nervous system. In addition, the vasodilators have no role in the treatment of these disorders( patients with these disorders may have urinary frequency, hesitancy or incontinence)
6- We have to discuss here the Overactive Bladder Syndrome (OBS) with more details. This syndrome has the same symptoms than bladder dysfunction (urinary frequency, urgency, urge incontinence and nocturia). The overactive bladder contracts suddenly without you having control and when the bladder is not full. The medical science could not find any cause of this syndrome. Overactive bladder syndrome is sometimes called an Irritable Bladder or Detrusor Instability. The recommended treatment consists of some general lifestyle measures, bladder training, pelvic floor exercises and medications.
The medication includes the class of drugs called antimuscarinics (or anticholinergics) which are oxybutynin, tolterodine, trospium chloride, propiverine, and solifenacine. These drugs work by blocking certain nerve impulses to the bladder, which relaxes the bladder muscle and so increases the bladder capacity. Medication improves symptoms in some cases, but not all. The side-effects are quite common : dry mouth, dry eyes, constipation, and blurred vision.
Other treatment includes surgery (sacral nerve stimulation, augmentation cystoplasty, urinary diversion. The treatment with botulinum toxin A is not approved by Food and Drugs Administration.
In overactive bladder syndrome, all the patients did not have it when they were much younger . They start to have it when they are 40 years of age or older. We see a clearly striking similarity with myocardial infarction (heart attack). In our bladder dysfunction, we have formulated a theoretical cause of the disease. We postulated the cause which is the hypoxia of the bladder by atherosclerosis and treat the cause directly with vasodilator agents, which re-establish the blood flow to the bladder and stop and/or alleviate the metabolic acidosis, the source of explosive and unpredictable muscle contractions. The response to the vasodilator agents was excellent with almost no troublesome side-effects like thoses of the anticholinergics. The excellent response to our treatment was the convincing experimental proof that our postulated cause was correct. For now, the cause of bladder dysfunction is not yet scientifically proven by multiple studies with larger sample sizes, but it has been practically proven by treatment with vasodilator medications such as Nifedipine.
CONCLUSION:
1- The Bladder Dysfunction causes symptoms in both men and women in advanced age (45 or older).
2- Benign prostatic hypertrophy and cancer must be ruled out before making the diagnosis of Bladder Dysfunction.
3- Multiple studies with large sample sizes, angiographic investigation of the vesical arteries, and measurement of urine flow pre- and post-treatment with vasodilator agents will support our hypothesis.
4- Bladder dysfunction is an age-related malfunction of the bladder by hypoxia secondary to atherosclerosis.
Notice:
This is a Free Medical Science Information to serve the humanity. If you like the treatment of Bladder Dysfunction, consult your doctor : Ask him or her if this treatment is good for your problem?.
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