Defining urge as an uncontrolled micturition explains pathogenesis, informs cure and helps solve the burgeoning OAB crisis

Abstract

Background Parallel with the demographic ageing crisis, is a disabling overactive bladder (OAB) crisis (urgency/frequency/nocturia), 30% prevalence in older women, pathogenesis stated as unknown and, according to some learned societies, incurable. Hypothesis/Aims To review International Continence Society and Integral System paradigms to test our thesis that OAB per se is not a pathological condition, rather, a prematurely activated uncontrolled micturition; pathogenesis being anatomical damage in a nonlinear feedback control system comprising cortical and peripheral (muscle/ligament) components. Methods We examined studies from basic science, anatomy, urodynamics, ultrasonic and video xrays, ligament repairs, from which we created a nonlinear binary model of bladder function. We applied a Chaos Theory feedback equation, Xnext = Xc(1 − X) to test our hypothesis against existing concepts and hypotheses for OAB pathogenesis. Results The bladder has ONLY two modes, EITHER closed OR open (micturition). Closure is reflexly controlled cortically and peripherally: muscles contracting against ligaments stretch the vagina to suppress afferent signals to micturate from urothelial stretch receptors. “OAB” can be caused by anatomical damage anywhere in the model, by childbirth or age‐weakened ligaments, which can be repaired to cure all three OAB symptoms. Urodynamic “DO” graphs are interpreted anatomically and by the feedback equation. Conclusion OAB is in crisis. Our thesis of OAB as an uncontrolled micturition from anatomical defects in the bladder control system provides fresh directions for further development of new treatments, nonsurgical and surgical, to help break the crisis and bring hope and cure to 600 million women sufferers.

The integral theory physiologically guides mathematical models of bladder/bowel function and dysfunction

“…Clinical models based on the theory, such as the diagnostic algorithm, have been predictive of ligament weakness and surgical cure. Mathematical models (Figures 1 and 2) [3][4][5][6][7][8][9][10] have provided significant insights into the three functions (and dysfunctions) of the bladder described by the Integral Theory: urethral closure, evacuation, and prevention of premature activation of the micturition reflex (urge incontinence). 2 Until it is experimentally falsified, the Theory serves as an adequate starting point, at least as regards the female pelvic floor.…”

“…The equation was able to model every mode of the bladder: retention; normal; low compliance; bladder instability. 8,9 F I G U R E 2 The exponential nature of urine flow is related to urethral diameter, For a flow rate of 50 mL/s. (thick blue line), opening the urethral diameter from 3.5 to 4 mm reduces the head of pressure required by the detrusor to expel urine from the bladder from 172 to 100 cm water.…”

“…The IT's discoveries that pelvic muscles contract against ligaments to close urethra (continence), open urethra (urine evacuation), stretching bladder base to control premature activation of micturition reflex (urgency), allows measurement of its component parts, as inputs for the above functions. [3][4][5][6][7][8][9][10] Weak ligaments decrease the muscle forces acting on the urethra (Figure 1). Mathematical modeling can be assisted by ultrasound to measure inputs from ligament lengthening and urethral diameter during effort; by urodynamics to measure urethral pressure and flow inputs, with or without mechanical support of structures.…”

A brief physiology and pathophysiology of the bladder

“…With reference to Figure1A , the binary control works like an electric switch to control two different reflexes, either closed or open (micturition) ( 2 ) (see Videos S2,S3 ). These reflexes are mutually exclusive, with cortical and peripheral components for each function.…”

A response to Dr. Petros and a note on models and theories

“…Our argument for deficits in neural LUT control models are likewise that they are weakly integrated into larger efforts that include biomechanics or other LUT components. Dr. Petros references an interesting theory of neural gating variables that effectively act as a binary controller for storage and micturition reflex activation, 11 not dissimilar to the “switching circuits” hypothesis 12 . This is a powerful descriptive model for explaining pathology.…”