Therapeutic effect of Low intensity Extracorporeal Shock Wave Therapy (Li-ESWT) on diabetic bladder dysfunction in a rat model

Yung-Chin Lee, Tusty-Jiuan Hsieh, Fang-Hsiang Tang, Jhen-Hao Jhan, Kun-Ling Lin, Yung-Shun Juan, Hsun-Shuan Wang, Cheng-Yu Long, Yung-Chin Lee, Tusty-Jiuan Hsieh, Fang-Hsiang Tang, Jhen-Hao Jhan, Kun-Ling Lin, Yung-Shun Juan, Hsun-Shuan Wang, Cheng-Yu Long

Abstract

Objectives: Low intensity extracorporeal shock wave therapy (Li-ESWT) has proven to be effective and safe for the treatment of various urological disorders including erectile dysfunction and chronic pelvic pain syndrome. In this study, we elucidated the therapeutic effect and possible mechanisms of Li-ESWT on diabetic bladder dysfunction (DBD) in a rat model. Materials and Methods: In all, thirty-two female Sprague-Dawley rats were divided into three groups: normal control (NC), diabetes mellitus (DM) control, and DM Li-ESWT. The two DM groups were given high fat diets for one month, followed by 2 intraperitoneal injections of streptozotocin (STZ) 30 mg/kg separated by one week. Body weight and fasting blood glucose were monitored every week. Only rats with fasting blood glucose 140 mg/dL or more were considered diabetic and used in the subsequent portions of the study. The Li-ESWTs were applied toward the pelvis of the rats twice a week for 4 weeks with energy flux density (EFD) 0.02 mJ/mm2, 500 shocks, at 3Hz. All rats underwent plasma insulin tolerance test, conscious cystometry, leak-point pressure (LPP) assessment, and immunohistochemical studies. Results: DM groups had significantly lower insulin sensitivity and higher body weight. Conscious cystometry also revealed voiding dysfunctions. In the DM Li-ESWT group, the rats had significantly improved voiding functions that were reflected in longer micturition intervals and higher LPP compared to DM control. Immunofluorescence in DM control groups showed increased tyrosine hydroxylase (TH) expression and decreased neuronal nitric oxide synthase (nNOS) expression in the longitudinal urethral smooth muscles. Besides, rats had dilations and deformities of suburothelium capillary network of the bladder, revealing the deterioration of the nerve function of the urethra and destruction of the vascularization of the bladder. However, the DM Li-ESWT group exhibited recovery of the nerve expression of the urethra and vascularization of bladder. Conclusions: Li-ESWT ameliorates the bladder dysfunction and urinary continence in the DBD rat model, reflected in restoration of the nerve expression of the urethra and the vascularization of the bladder. Non-invasive Li-ESWT could be an alternative therapeutic option for DBD.

Keywords: bladder dysfunction; diabetes mellitus; low intensity extracorporeal shock wave.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interest exists.

© The author(s).

Figures

Figure 1
Figure 1
Time flow chart. SW: shock wave. STZ: streptozotocin. ITT: insulin tolerance test.
Figure 2
Figure 2
Body weights (A) and insulin tolerance test (B). The body weights were recorded weekly. The insulin tolerance test was performed after 5 weeks of STZ injection. The data are mean ± SD. Normal control group: n = 10; diabetic group: n = 22.
Figure 3
Figure 3
Assessment of voiding function with conscious cystometry. (A) Normal voiding pattern was noted in 9 rats of the control group and 7 rats of the DM+Li-ESWT group. (B) Overactive bladder pattern was noted in one rat of the control group, 6 rats of the DM group and one rat of the DM+Li-ESWT group. (C) Underactive bladder pattern was noted in 2 rats of the DM group and 2 rats of the DM+Li-ESWT group. (D) Acontractile bladder pattern was noted in 2 rats of the DM group and 2 rats of DM+Li-ESWT group, which was also regarded as abnormal voiding pattern. (E) Pie charts of the voiding patterns. Normal voiding patterns were significantly more common (P

Figure 4

(A) Representative cross sectional images…

Figure 4

(A) Representative cross sectional images of the urethral smooth muscles stained with Alexa…

Figure 4
(A) Representative cross sectional images of the urethral smooth muscles stained with Alexa 488 conjugated phalloidin (Pha; green fluorescence) and the sympathetic nerves stained with anti-tyrosine hydroxylase (TH; red fluorescence) antibody. Compared to the control group, urethras in the DM group demonstrated higher TH expression in longitudinal smooth muscles, which was improved after Li-ESWT. (B) Representative cross sectional images of the urethral smooth muscles stained with Alexa 488 conjugated phalloidin (Pha; green fluorescence) and the nitric nerves stained with anti-neuronal nitric oxide synthase (nNOS; red fluorescence) antibody. Compared to the control group, urethras in the DM group showed lower nNOS expression in longitudinal smooth muscles, which was improved after Li-ESWT. (C) Representative images of the bladder suburothelium stained with anti-collagen IV (Col IV; red fluorescence) antibody. Compared to the normal controls, dilations and deformities of suburothelium capillary network were noted in the DM rats, which were improved after Li-ESWT. All the tissue sections were counterstained with 4',6-diamidino-2-phenylindole (DAPI; blue fluorescence) to identify the cell nuclei.
Figure 4
Figure 4
(A) Representative cross sectional images of the urethral smooth muscles stained with Alexa 488 conjugated phalloidin (Pha; green fluorescence) and the sympathetic nerves stained with anti-tyrosine hydroxylase (TH; red fluorescence) antibody. Compared to the control group, urethras in the DM group demonstrated higher TH expression in longitudinal smooth muscles, which was improved after Li-ESWT. (B) Representative cross sectional images of the urethral smooth muscles stained with Alexa 488 conjugated phalloidin (Pha; green fluorescence) and the nitric nerves stained with anti-neuronal nitric oxide synthase (nNOS; red fluorescence) antibody. Compared to the control group, urethras in the DM group showed lower nNOS expression in longitudinal smooth muscles, which was improved after Li-ESWT. (C) Representative images of the bladder suburothelium stained with anti-collagen IV (Col IV; red fluorescence) antibody. Compared to the normal controls, dilations and deformities of suburothelium capillary network were noted in the DM rats, which were improved after Li-ESWT. All the tissue sections were counterstained with 4',6-diamidino-2-phenylindole (DAPI; blue fluorescence) to identify the cell nuclei.

References

    1. Guariguata L, Whiting DR, Hambleton I. et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014;103:137–49.
    1. Goldstraw MA, Kirby MG, Bhardwa J. et al. Diabetes and the urologist: a growing problem. BJU Int. 2007;99:513–7.
    1. Yoshimura N, Chancellor MB, Andersson KE. et al. Recent advances in understanding the biology of diabetes-associated bladder complications and novel therapy. BJU Int. 2005;95:733–8.
    1. Barness LA, Opitz JM, Gilbert-Barness E. Obesity: genetic, molecular, and environmental aspects. Am J Med Genet A. 2007;15:3016–34.
    1. Pan FC, Wright C. Pancreas organogenesis: from bud to plexus to gland. Dev Dyn. 2011;240:530–65.
    1. Chatzigeorgiou A, Halapas A, Kalafatakis K. et al. The use of animal models in the study of diabetes mellitus. In vivo. 2009;23:245–58.
    1. Liang D, Zhang Y, Han J. et al. Embryonic stem cell-derived pancreatic endoderm transplant with MCT1-suppressing miR-495 attenuates type II diabetes in mice. Endocr J. 2015;62:907–20.
    1. Pagliuca FW, Millman JR, Gurtler M. et al. Generation of functional human pancreatic beta cells in vitro. Cell. 2014;159:428–39.
    1. Zhang H, Qiu X, Shindel AW. et al. Adipose tissue-derived stem cells ameliorate diabetic bladder dysfunction in a type II diabetic rat model. Stem Cells Dev. 2012;21:1391–400.
    1. Ioppolo F, Rompe JD, Furia JP. et al. Clinical application of shock wave therapy (SWT) in musculoskeletal disorders. Eur J Phys Rehabil Med. 2014;50:217–30.
    1. Ito K, Fukumoto Y, Shimokawa H. Extracorporeal shock wave therapy for ischemic cardiovascular disorders. Am J Cardiovasc Drugs. 2011;11:295–302.
    1. Mense S, Hoheisel U. Shock wave treatment improves nerve regeneration in the rat. Muscle Nerve. 2013;47:702–10.
    1. Gruenwald I, Appel B, Vardi Y. Low-intensity extracorporeal shock wave therapy-a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy. J Sex Med. 2012;9:259–64.
    1. Zimmermann R, Cumpanas A, Miclea F. et al. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study. Eur Urol. 2009;56:418–24.
    1. Qiu X, Lin G, Xin Z. et al. Effects of low-energy shockwave therapy on the erectile function and tissue of a diabetic rat model. J Sex Med. 2013;10:738–46.
    1. Zhang M, Lv XY, Li J. et al. The characterization of high-fat diet and multiple low-dose streptozotocin induced type 2 diabetes rat model. Exp Diabetes Res. 2008;2008:704045.
    1. Albersen M, Fandel TM, Zhang H. et al. Pentoxifylline promotes recovery of erectile function in a rat model of postprostatectomy erectile dysfunction. Eur Urol. 2011;59:286–96.
    1. Srinivasan K, Viswanad B, Asrat L. et al. Combination of high-fat diet-fed and low-dose streptozotocin-treated rat: a model for type 2 diabetes and pharmacological screening. Pharmacol Res. 2005;52:313–20.
    1. Daneshgari F, Liu G, Birder L. et al. Diabetic bladder dysfunction: current translational knowledge. J Urol. 2009;182:S18–26.
    1. Hayashi D, Kawakami K, Ito K. et al. Low-energy extracorporeal shock wave therapy enhances skin wound healing in diabetic mice: a critical role of endothelial nitric oxide synthase. Wound Repair Regen. 2012;20:887–95.
    1. Ohtori S, Inoue G, Mannoji C. et al. Shock wave application to rat skin induces degeneration and reinnervation of sensory nerve fibres. Neurosci Lett. 2001;23:57–60.
    1. Wang B, Ning H, Reed-Maldonado AB. et al. Low-Intensity Extracorporeal Shock Wave Therapy Enhances Brain-Derived Neurotrophic Factor Expression through PERK/ATF4 Signaling Pathway. Int J Mol Sci. 2017;16:18.
    1. Lin G, Reed-Maldonado AB, Wang B. et al. In situ Activation of Penile Progenitor Cells with Low-Intensity Extracorporeal Shockwave Therapy. J Sex Med. 2017;14:493–501.
    1. Li H, Matheu MP, Sun F. et al. Low-energy Shock Wave Therapy Ameliorates Erectile Dysfunction in a Pelvic Neurovascular Injuries Rat Model. J Sex Med. 2016;13:22–32.
    1. Kuo YR, Wu WS, Hsieh YL. et al. Extracorporeal shock wave enhanced extended skin flap tissue survival via increase of topical blood perfusion and associated with suppression of tissue pro-inflammation. J Surg Res. 2007;143:385–92.
    1. Wang HS, Oh BS, Wang B. et al. Low-intensity extracorporeal shockwave therapy ameliorates diabetic underactive bladder in streptozotocin-induced diabetic rats. BJU Int. 2018;122:490–500.
    1. Wang B, Zhou J, Banie L. et al. Low-intensity extracorporeal shock wave therapy promotes myogenesis through PERK/ATF4 pathway. Neurourol Urodyn. 2018;37:699–707.
    1. Jin Y, Xu L, Zhao Y. et al. Endogenous Stem Cells Were Recruited by Defocused Low-Energy Shock Wave in Treating Diabetic Bladder Dysfunction. Stem Cell Rev Rep. 2017;13:287–98.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe