Abnormal electromyographic activity of the urethral sphincter,

A potential association between abnormal electromyographic activity-that is, decelerating bursts and complex repetitive discharges-of the urethral sphincter and difficulty in voiding was examined in 57 women with urinary retention. Abnormal electromyographic activity was found in 33. Ultrasonography of the ovaries in 22 of the 33 women showed that 14 had polycystic ovaries. Of the other eight women, two had had oophorectomies, one had shrunken ovaries and ovarian failure, and one had previously undergone oophorectomy and the other ovary could not be seen; in one neither ovary could be seen, and three had ovaries of normal appearance, although two of these women were taking the contraceptive pill. Thirteen of the group had endocrine symptoms and signs characteristic of the polycystic ovary syndrome. Videocystometrography in 17 ofthe women who were examined by ultrasonography showed low flow rates and high residual volumes of urine after micturition in 12 women who could void, the other five having chronic urinary retention. A speculative hypothesis for the observed association of impaired voiding, abnormal electromyographic activity of the urinary sphincter, and polycystic ovaries is advanced, based on the relative progesterone deficiency that characterises the polycystic ovary syndrome. Progesterone stabilises membranes, and its depletion might permit ephaptic transmission of impulses between muscle fibres in the muscle of the urethral sphincter, giving rise to the abnormal electromyographic activity. This may impair relaxation of the sphincter, resulting in low flow rates of urine, incomplete emptying of the bladder, and, finally, urinary retention. than normal ovaries (mean volume 5 8 ml (4 6 to 7 3)), with a highly echogenic and dense central stroma and numerous (>10) peripherally located cysts of 4-6 mm in diameter.5 When associated with hirsutism, greasy skin, obesity, menstrual irregularity, and infertility the polycystic ovary syndrome may be the diagnosis.6 This condition is associated with increased concentrations of circulating androgens and luteinising hormone (with normal concentrations of follicle stimulating hormone) and, in 30% of cases, hyperprolactinaemia7 and occurs in 25% of women with amenorrhoea and 90% of those with hirsutism.' Patients and methods Fifty seven women with difficulties in voiding were referred to the department of clinical neurophysiology at the Middlesex Hospital during 1982-8 for electromyography of the urethral sphincter. The indication was retention of urine or dysfunction of voiding. The referring doctors were aware of our interest in the electromyographic abnormality,' and patients were clearly selected. Each patient underwent electromyography of the urethral sphincter with a concentric needle electrode,9-" and abnormal electromyographic activity (that is, decelerating bursts and complex repetitive discharges) was found in 33. Pelvic ultrasonography was carried out in 22 of the 33 women (the other 11, who had been early subjects and as secondary referrals from long distances could not be readily recalled, were not available). Ultrasonography was performed by one of two experienced radiographers with a 3 MHz long focused transducer attached to an Aloka 720 high resolution sector scanner. A history of pelvic operations or menstrual irregularity and the presence of hirsutism or acne were recorded. Departments of Clinical Neurophysiology and Urology, Middlesex Hospital, London WIN 8AA Clare J Fowler, MRCP, consultant Timothy J Christmas, FRCS, research registrar Christopher J Chapple, FRCS, senior registrar Helen Fitzmaurice Parkhouse, FRCS, research regzstrar Roger S Kirby, FRCS, senior registrar Department of Reproductive Endocrinology, University College and Middlesex School of Medicine, London WIN 8AA Howard S Jacobs, FRCP, professor Correspondence to Dr Clare J Fowler, Department of Clinical Neurophysiology, Middlesex Hospital, London WIN 8AA. Introduction Abnormal electromyographic activity of the urethral sphincter (that is, decelerating bursts and complex repetitive discharges) has been described in women with retention of urine.'I Detailed analysis showed that it is typical of the type of repetitive, circuitous, self excitatory activity that results from ephaptic excitation between muscle fibres.2 Such abnormal activity has been suggested to prevent adequate relaxation of the sphincter during voiding, causing outflow obstruction of the bladder, an increased residual volume of urine, and eventually failure of the detrusor. 2 Early in the course of investigating urinary retehtion in women by electromyography of the urethral sphincter we observed that a particular facies recurred, two women having typical features of the SteinLeventhal syndrome. An association of abnormal electromyographic activity, impaired sphincter relaxation, and ovarian dysfunction was suspected, and ovarian ultrasonography was performed when possible in subsequent cases. On reviewing the literature an obscure report was found of two cases of "psychogenic urinary retention" occurring after laparotomy, at which cysts on the ovaries were the only abnormal finding.4 Polycystic ovaries have several features that are conspicuous on both histological examination and high resolution ultrasonography; they are larger (mean volume 11 -2 ml (95% confidence interval 10 7 to 11 7)) Results In 33 women electromyography of the urethral sphincter showed profuse spontaneous decelerating bursts and complex repetitive discharges. Brief bursts of this type of electromyographic activity can occasionally be induced in the muscle of the urethral sphincter by movement of the needle, and a requirement for considering that the activity was abnormal was that it was widespread and spontaneous.2 Fourteen of the women presented with urinary retention, 17 with difficulty in voiding, and two with overflow incontinence. Urodynamic studies were carried out in 17 women, and obstruction at the region of the striated sphincter was observed in all 12 who could still void. Instability of the detrusor was shown in four, a hypocontractile detrusor in three, and apparently normal detrusor function in 10. Of the 22 patients who had pelvic ultrasonography, 14 showed the characteristic features of polycystic ovaries. Of the eight remaining women, two had had bilateral oophorectomies; one had had a unilateral oophorectomy for ovarian cysts, and the other ovary could not be seen on ultrasonography; one had shrunken ovaries caused by premature ovarian failure; and in another neither ovary could be seen; in three the ovaries appeared normal, although two of these women were taking the contraceptive pill. In the 22 women a BMJ VOLUME 297 3 DECEMBER 1988 1436 history of menstrual irregularity was recorded in 13, hirsutism in seven, and acne or greasy skin in seven (table I). Endocrine assays were performed in nine of the patients (table II). Serum testosterone concentrations (mean 2 7 nmol/l) were at or above the upper limit of the normal range (0-5-2 5 nmol/l) in seven of the patients. Serum concentration of luteinising hormone was above the normal range (5-12 U/1) in four of the patients (mean 15 4 U/1, range 3-6-43-8 U/1). In all eight patients tested serum concentration of follicle stimulating hormone was within normal limits (1 0-4-0 U/1). The serum prolactin concentration was above the normal upper limit (700 mU/l) in two patients. TABLE I-Characteristics ofthe women with difficulties in voiding, abnor?nal responses on electromyography, and polycystic ovaries Age Duration of Rate of urine flow Case No (years) symptoms (years) Symptoms (mt/s) Urodynamic findings 1 37 8 Difficulty in voiding 12 Instability of detrusor 2 34 11 Difficulty in voiding Failure of detrusor 3 21 1 1 Difficulty in voiding 15 Stable detrusor 4 27 14 Difficulty in voiding 9 Instability of detrusor 5 39 5 Difficulty in voiding 12 Stable detrusor 6 46 12 Difficulty in voiding 9 Stable detrusor 7 21 4 Urinary retention 8 Stable detrusor 8 27 2 Urinary retention Stable detrusor 9 45 10 Urinary retention Failure of detrusor 10 32 13 Urinary retention 7 Instability of detrusor 11 33 12 Urinary retention Failure of detrusor 12 34 11 Urinary retention Instability of detrusor 13 23 7 Urinary retention Stable detrusor 14 23 12 Urinary retention Stable detrusor TABLE II-Hormonal profile ofwomen with abnormal responses on electromyography and polycystic ovaries Luteinising Weight/ Testosterone hormone Prolactin Case No Symptoms (height)' (nmol/l) (U/1) (mU/l) 1 Oligomenorrhoea 21-6 2 Acne, hirsutism, amenorrhoea 718-0 3 Hirsutism 19-4 2 5 6-0 505-0 4 Acne, hirsutism, amenorrhoea 21 8 3-6 43-8 296-0 5* 22-8 6 Menorrhagia 24-7 7 Acne, hirsutism, oligomenorrhoea 21-3 3-3 13 7 736-0 8 Acne, hirsutism 19-7 1-6 9 0 9 Oligomenorrhoea 23-7 10 Menorrhagia, hirsutism, 21-7 11 Oligomenorrhoea 2-6 11-6 316-0 12 Acne, hirsutism, oligomenorrhoea 21-0 3-3 19 0 2%0 13 Oligomenorrhoea 28-6 2-5 12-5 14 Acne 20 8 2-5 7-3 373 0 *Symptoms not known. Five women were treated with cyproterone and ethinyloestradiol. 12 Despite improvement in their skin they did not notice any lasting improvement in their urinary symptoms. Six were treated with phenytoin, but none reported any symptomatic benefit. Urethral dilatation under general anaesthesia was similarly ofno long term benefit in nine patients, and those with retention continued to be optimally managed by clean intermittent self catheterisation.