ISSN0535-1405

No. 513

September 30, 2022
Published by International Medical Society of Japan,
Chairman, Board of Directors: Kenichi Ishibashi, MD, PhD
Editors: K. Ito, MD, PhD, T. Kondo, MD, PhD,
K. Ichihashi, MD, PhD, T. Murakami, PhD, R.Nagai, MD, PhD,
I. Taniguchi, MD, PhD, and T. Yamazaki, MD, PhD
3F MK Sangenjaya Building, 1-15-3 Kamiuma, Setagaya-ku,Tokyo154-0011,Japan.
TEL 03(5486)0601 FAX 03(5486)0599 E-mail: imsj@imsj.or.jp https://www.imsj.or.jp/

The 455th International Symposium on Therapy
The 455th International Symposium on Therapy

Meanwhile, in recent years, guidelines for chronic

was held by the Zoom Webinar on July 21, 2022.

constipation have been developed and several

Dr. Taro Kondo, Managing Director of the

new medications have become available, andInternational Medical Society of Japan (IMSJ),

the diagnosis, treatment, etc. of overactive

presided over the meeting.

bladder, which relieves urinary urgency, has comeTopics related to excretion
Introductory Message from the Chair

to assume a more important role not only for
urologists but for internists.
In Lecture I, Takeshi Mizukami M.D, Ph.D, theTaro Kondo, MD, PhD
Managing Director, IMSJ

head doctor, Dept. of Endoscopy Center,Thank you for watching our web lecture in thewill speak on “Pathophysiology of chronic

midst of the 7th wave of the COVID-19 pandemic.

constipation inferred from abdominal X-rays andSetting the theme of the 455th International

its treatment-effects of the social situation- ”,

Symposium on Therapy as “Topics related towhile in Lecture II, Hikaru Tomoe MD, PhD,

excretion”, we have invited two doctors, one fromthe professor, Department of Urology, Pelvic

internal medicine and the other from urology,

Reconstructive Surgery Adachi Medical Center,to deliver a lecture.

Tokyo Women's Medical University will talk about

Especially in actual outpatient and home health“Treatment of urinary frequency and urinary

care settings for the elderly, there are many

incontinence”

issues related to their defecation and urination.

NHO Kurihama Medical and Addiction Center,

Page 8International Medical News

"Colon morphological abnormalities" such

LectureⅠ
Pathophysiology of chronic
constipation inferred from abdominal
X-rays and its treatment-effects of the social situationTakeshi Mizukami M.D, Ph.D
The head doctor
Dept. of Endoscopy Center
NHO Kurihama Medical and Addiction Centeras sigmoid colon malrotation and " Colon
motility abnormalities” such as non-transporting
segmental movements observed with anunanesthetized colonoscope, are factors thatmake colonoscopy difficult.
In constipation-predominant irritable bowel
syndrome, which has abdominal pain associatedwith bowel movements, "colon morphologicalabnormalities" and "colon motility abnormalities"

Chronic constipation is a functional bowel

are more frequently observed, and the cecal

dysorder, symptoms of difficult, infrequent, or

intubation time is twice as long in IBS patients as inincomplete defecation predominate that persists

asymptomatic patients.

for several months.
The difficulty in treating chronic constipation isColon morphology abnormalities inhibitsthat the patients do not understand their condition.

defecation as it inhibit colonoscopic insertion,and it may cause abdominal pain associatedMechanical obstraction, medications, andwith defecation and colonoscopic insertion

systemic illnesses can cause constipation and mustin constipation-predominant irritable bowel

be excluded, especially in new onset patients.

syndrome with normal-transit time.

Functional constipation is caused by disordered
function of the colon and requires treatment of

Non-transporting segmental movements may

itself.

cause abdominal pain, and prolong the colontransit time and reduce stool tightly, resulting inChronic constipation can be divided into 3

constipation-predominant irritable bowel syndrome

broad categories: 1) Normal-transit constipation:with slow-transit time. The stress events such as

Idiopathic constipation, constipation-"going on a trip" are the triggers for constipation

dominant irritable bowel syndrome, secondary

in patients with colon motility abnormalities

constipation such as drug-induced constipation(Intestinal Reseach 2017). As an indication ofand symptomatic constipation, 2) Slow-transit

the same phenomenon, thirty percent ofconstipation: Constipation-dominant irritable bowel

constipated patients are stress-related and theirsyndrome, and 3) Defecatory or rectal evacuation

abdominal X-rays showed colonic spasm anddisorders: Rectal constipation and Dyssynergia.

hard, reduced stools (Gastroenterology. 1949) .

Above 3 different pathophysiological conditions
may overlap, which makes difficult to manage.

Summarizing these colon-related findings ofFurthermore, at present in Japan, there is no way

endoscopy, abdominal X-ray, and interview,to diagnose the pathophysiological conditions.

(1)Slow transit constipation: Stress-related
constipation-predominant irritable bowel

Exclusion of organic diseases is the most important

syndrome and idiopathic constipation (spastic

issue in the treatment of chronic constipation,

constipation).

and colonoscopy is often performed.

From abdominal X-ray, the stool is hard and

It is well known that colonoscopy in patientssmall, sometimes colonic spasms are observed.

with constipation is difficult, indicating that the(2)Normal transit constipation: Constipation-difficulty contributes to constipation.

predominant irritable bowel syndrome. Colonmorphological abnormalities inhibit the bowel

Page 9movement and cause pain.
From abdominal X-ray, sigmoid colon malrotation
and universal mesenterium commune areobserved and the stool is not so hard and small.
(3)Defecatory or rectal evacuation disorders:International Medical News

LectureⅡ
Treatment of urinary frequency andurinary incontinence

retention in the rectum and reduces rectal

Hikaru Tomoe MD, PhD
Professor
Department of Urology, Pelvic Reconstructive Surgery
Adachi Medical Center, Tokyo Women's Medical University

perception. Dyssynergia is a defecatory disorder

A large epidemiological survey on lower urinary

Rectal constipation due to decreased rectal
perception, avoiding defecation leads to stoolthat causes constipation symptoms due to a failure
to effectively empty the rectum because of an
inability to coordinate abdominal, rectoanal, andpelvic floor muscles.
From abdominal X-ray, stool retension in rectum
without bowel movement is observed (Rectal
constipation), stool retension in rectum with feelingof residual stool is observed (Dyssynergia),
Rendering a confident diagnosis, while providing

tract symptoms (LUTS) in Japan showed that
nocturia and increased daytime urinary frequency
are the most common LUTS in both men andwomen. The second most common LUTS in men isslow stream.
The incidence of urinary incontinence in women
increases with age. The percentages of women
aged ≥ 20 years and ≥ 40 years with this conditionare 25% and 40%, respectively; however, theboth education and reassurance, is the essence

percentage of patients who receive treatment isof treatment.

low (around 30%). Stress urinary incontinence (SUI)(1) Slow transit constipation reduces the stool

accounts for 49% cases of urinary incontinence.

due to stress. Teach them not to stress itself.

SUI can be defined as urine leakage that occurs(2) Normal transit constipation causes difficultywhen abdominal pressure exceeds urethral

in defecation and abdominal pain. Instructpressure like during coughing, sneezing, or

stretching and exercise in order to improve

exercise. Pregnancy, delivery, and obesity are

the passage of stool regardless of colon
morphological abnormalities.
(3) Defecatory or rectal evacuation disorders is
mainly caused by reduced rectal perception.
Acting on the call to defecate and scheduling
visits to the toilet are suggested. Dyssynergia
requires special treatment in the proctology
department.
Behavioral restrictions and psychosocial stress inknown to weaken the pelvic floor, causing urethral
hypermobility and intrinsic urethral weaknesses,
and ultimately leading to SUI. Pelvic floor muscle
training (PFMT) and weight loss protocols are
effective therapeutic strategies. Radical surgicaltherapeutic techniques include midurethral slingoperations (such as tension-free vaginal tape andtransobturator tape operations).
Overactive bladder (OAB) syndrome is characte

the recent situation affect the above-mentioned

rized by subjective symptoms such as urgency,

pathophysiology of chronic constipation. Present

increased daytime frequency, nocturia, anda case and explain the above pathophysilogy ofurgency urinary incontinence (UUI). OAB affects

it.

12.4% of individuals aged ≥ 40 years, and its
prevalence is known to increase with age.
The percentages of patients with OAB andconcomitant UUI were 41% and 64% in men andwomen, respectively. This condition negatively
affects the patient’s quality of life. Avoiding

Page 10

International Medical News

excessive fluid intake to control urine output isinsurance in April 2020 in Japan. Approximately 50%

the standard treatment in these patients. Pelvicof patients with POP concomitantly experience

floor muscle training (PFMT) and bladder training

OAB; however, OAB symptoms usually disappear or

are also effective strategies. Pharmacologicalimprove in approximately 60% of these patients iftherapy using anticholinergic agents remains thethe POP is repaired using pessary or by surgery. This

mainstay of treatment for patients with OAB andis because POP is usually accompanied by bladderconcomitant UUI. However, these medications

outlet obstruction. The mechanism underlying thisare associated with adverse drug reactions

concomitant disease is similar to that underlying

such as constipation, mouth dryness, and visual

the relationship between OAB and benign prostatic

accommodation disorders, and may also lead

hypertrophy (BPH).

to cognitive decline. Therefore, β3-adrenoceptor

BPH is typically a condition with hypertrophy ofagonists are considered the first-line drugs,

prostate, BOO and LUTS. The prevalence of BPH

particularly in older adults. Both patients who

increases with age. BPH is associated with not only

cannot tolerate high doses of OAB drugs due tomicturition and post-micturition symptoms, but also

adverse drug reactions and patients who don't

OAB which is one of storage symptoms. As medical

respond well to the drugs after 8- to 12-weeks

treatment, there are α1 blocker, 5α-reductase

are diagnosed with refractory OAB. Intravesicalinhibitor and PGE5 inhibitor, and surgical therapy

injection of botulinum toxin A, which can beis performed in cases in which the effect of theperformed in an outpatient setting, is effective in

medical treatment is insufficient. OAB induced

such cases. Another treatment option for refractoryby BPH disappears or improves when the BOO

OAB is sacral neuromodulation implant placement;is released by α1 blocker or surgery, but if OAB

however, this technique is more invasive than thesymptom does not improve, the drug for OAB is

intravesical injection of botulinum toxin A andadministered.

requires hospitalization.

Nocturia is the most frequent symptom for both

A cystocele is a form of pelvic organ prolapse

men and women, and it is the most influential(POP). In addition to dysuria and defecation

symptom in daily life. The causes of nocturia

disorder, patients with POP experience

include polyuria, nocturnal polyuria, bladderconcomitant OAB symptoms. The risk factors forurinary storage disorder, and sleep disorder.

POP include advanced age, pregnancy, vaginal

Of these causes, nocturnal polyuria is the mostdelivery, obesity, and hysterectomy. There arecommon, and nocturnal polyuria occurs in about

few reports that show that PFMT is effective in

80% of patients with nocturia. Most of the causes

mild cases (i.e., stages below stage II); however,of nocturnal polyuria come from medical disorders

it has virtually no effect on severe cases. Pessary

such as obstructive sleep apnea syndrome, occultis also useful for treating POP. However, thecongestive heart failure and lower limb edema.

continuation of pessary is difficult in many cases

After these diseases are treated, nocturnal polyuria

because it occasionally slips down unintentionallywill decrease and nocturia will also improve.

and the insertion is not suitable in patients withvaginal erosion. Transvaginal mesh surgery andlaparoscopic sacrocolpopexy, which enable
uterine prolapse repair without hysterectomy,
have recently been performed. Robotic-assisted
sacrocolpopexy was covered by the healthPage 11

International Medical News● U kraine has been becoming a military fort

Discourse
Introduction of the speaker of discourse
Taro Kondo, MD, PhD
Managing Director, IMSJ
Mr. Taisuke Abiru, Senior Research Fellow, The
Sasakawa Peace Foundation, will give a lecture
titled “Ukrainian war and the world after that”.
On February 24, about 5 months before the settingof this project, Russia launched missile attacks.
This war is still going on, and now takes on the
aspect of a proxy war by the West providing new
weapons to Ukraine in addition to an invasion of
Ukrainian territory by Russia. The world economy
has become unstable due to many difficult issues,
including energy problems represented by oil andby NATO. The possibility of future Ukrainian
membership in NATO is posing an essential
threat to Russia.
→National security issue● T he Ukrainian government has no intentionof implementing the Minsk Protocol(on ceasefire/peace in the civil war in eastern
Ukraine). Instead, it is committing genocide
against people living there.
→Humanitarian issue● Historically, Russia and Ukraine are inseparable.
The independence of Ukraine leads to the total
denial of the past since the Russian Empire.
Ukraine has never been a true nation.
→Historical issue

natural gas, food problems resulting from the haltof wheat exports, and the problems of accepting

There are probably various ways to resolve thisrefugees. Why did Russia decide to invade? What

military invasion if it is really only a security and/will happen in the future? We would like to hear his

or a humanitarian issue, but, if it is a war based on

answers to those questions.

the historical view, there is probably no room forcompromise between the two sides.

Discourse: Ukrainian war and the world
after that
Taisuke Abiru
Senior Research Fellow
The Sasakawa Peace Foundation
Looking back to the Cold War era, there wasoriginally a Cold War structure between the Soviet

In the process leading up to this military invasion,
President Putin has published papers and madestatements externally that quite emphasize
historical issues:● In July 2021, President Putin published a paper on
the historical unity with Ukraine.

Union and the West in Europe then.
At that time, the North Atlantic Treaty Organization● O n June 9, 2022 (the 350th anniversary of the(NATO) and the Warsaw Pact Organization werebirth of Peter the Great), President Putin madefacing off against each other. However, after

the following statement:

the end of the Cold War and the collapse of the“ What Peter the Great did was to take backSoviet Union, while the Warsaw Pact Organization(our lands) and strengthened. The same task isdisappeared, NATO continued to expand

imposed on us.”eastward.

→President Putin's goal is not solely to prevent

The Soviet Union has been dismembered, and now

Ukraine from joining NATO, but to bring Ukraine

even Ukraine has started to think about joining

back under Russian influence.

NATO.
And, why President Putin has now launched a

Assuming President Putin's view of history, the goal

military invasion against Ukraine? He gives threeof this war would not be reached unless at least

reasons:

Russia completely controls the Novorossiya region,
which has a large Russian-speaking population,

Page 12International Medical News

including the Donbass region.

Also, Russia and Ukraine are the world's largest

I have recently traveled to America and discussed

exporters of pig iron. Russia is the world's second

with an expert, sharing the view that this battle islargest producer of aluminum after China.

very unlikely to be overwhelmingly won by either

Additionally, Russia is a major producer of cobalt

side and will probably be extended further andand copper.

further. The only positive prospect is that Russia will
only be able to continue the battle at the current● Aerospace/Aviation

pace for a few more months, and after that, it

R ussia is the third largest titanium producer in

may have to stop battling at least once in order

the world. The airspace over Russia is a major air

to supply soldiers and weapons. There could beroute.

a temporary cease-fire, for example, by the endof the year, but it would not mean a permanent

Given the above, it would be quite difficult topeace, and Putin would continue to battle withcompletely eliminate Russia from the global

setting his eyes on Novorossiya and other regions.

economy, and Russia has not been completely
eliminated yet. Since Russia is well aware of thisThis battle also has implications for the global

situation, it is putting pressure by tactically taking

economy as detailed below:

the global economy as a hostage including energy● Energy

and food issues.

Russia is the world's largest exporter of natural gas.
It is also the world's second largest oil exporter,

Prospecting how the world will be going forward,

and the world's third largest coal exporter. Further,

we tend to picture a confrontational structure

Russia is the world's largest supplier of enrichment

between the Western bloc imposing sanction

services for nuclear fuel used in nuclear poweron Russia and China/Russia, but the Global

plants. (Probably around 20% of nuclear fuel used

South countries take the stance of not entirely

in American nuclear power plants is provided

sanctioning Russia, not entirely on the side of thefrom Russian uranium enrichment services.)West, or not actively supporting Russia.
From a larger historical perspective, whereas the● Agriculture

former Cold War structure was one in which theR ussia is the largest exporter of wheat in the world.

U.S. and the Soviet Union divided the whole world

It is also a major producer of nitrogen, phosphorus,

in two, the world after this Ukraine war is not soand potassium - the three major components ofsimple. Specifically, although the Western bloc

fertilizer. In addition, Russia is the world's second

versus China and Russia have emerged as one

largest exporter of sunflower oil and safflower oil.

axis of conflict, the rest of the countries, the Global
South, play a very large part. Which side will take

● High-tech products/services

in such countries has become a key point, andRussia produces palladium more than any otherthis would be a long battle because it will not becountries in the world (32%), which is essential forsettled so easily.

semiconductors and electric vehicle batteries.

Japan was troubled even just by China and North

It accounts for 11% of the world's share of nickel

Korea in terms of its national security, but now that

production as well. Russia and Ukraine makehaving imposed economic sanctions on Russia, it

up 40-50% share of neon gas for semiconductor

will have to squarely consider these three countries

production.

from now on and is likely to face a very difficult
situation.

● MetalRussia is the world's third largest exporter of steel.