Abstract: Neurogenic bladder can be effectively managed with intermittent catheterization (IC) to improve or restore continence, but there is no consensus on which type of catheter is preferred. Hydrophilic catheters were developed to reduce urethral friction, thereby minimizing trauma and sticking, and making them more acceptable to the patient, and easier and safer to use. The objective of this article was to review the literature on the benefits of hydrophilic catheters in patients with neurogenic bladder.
Abstract: Lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) affects a large number of male patients from 45 years onward, increasing with age. Routine medical treatment is mainly limited to plant extracts, α-blockers, and 5-α-reductase inhibitors. Although all types of drug have a proven efficacy, they often do not sufficiently treat all aspects of LUTS related to BPH. Thus, there is a need for alternatives. Intraprostatic injections with botulinum neurotoxin type A (BoNT/A) seem to be a promising alternative. The purpose of this review is to summarize the most recent findings from basic science and clinical studies in relation to BoNT/A application in BPH-related LUTS, thereby providing insight into the putative mechanism of action, the rationale for the use of BoNT/A in BPH-related LUTS, and the clinical outcomes.
Abstract: Urinary incontinence is a frequent affliction in women and may be disabling and costly {LE1}. When consulting for urinary incontinence, it is recommended that circumstances, frequency and severity of leaks be specified {Grade B}. The cough test is recommended prior to surgery {Grade C}. Urodynamic investigations are not needed before lower urinary tract rehabilitation {Grade B}. A complete urodynamic investigation is recommended prior to surgery for urinary incontinence {Grade C}. In cases of pure stress urinary incontinence, urodynamic investigations are not essential prior to surgery provided the clinical assessment is fully comprehensive (standardised questionnaire, cough test, bladder diary, post-void residual volume) with concordant results {PC}. It is recommended to start treatment for stress incontinence with pelvic floor muscle training {Grade C}. Bladder training is recommended at first intention in cases with overactive bladder syndrome {Grade C}. For overweight patients, loss of weight improves stress incontinence {LE1}. For surgery, sub-urethral tape (retropubic or transobturator route) is the first-line recommended technique {Grade B}. Sub-urethral tape surgery involves intraoperative risks, postoperative risks and a risk of failure which must be the subject of prior information {Grade A}. Elective caesarean section and systematic episiotomy are not recommended methods of prevention for urinary incontinence {Grade B}. Pelvic floor muscle training is the treatment of first intention for pre- and postnatal urinary incontinence {Grade A}. Prior to any treatment for an elderly woman, it is recommended to screen for urinary infection using a test strip, ask for a bladder diary and measure post-void residual volume {Grade C}. It is recommended to carry out a cough test and look for occult incontinence prior to surgery for pelvic organ prolapse {Grade C}. It is recommended to carry out urodynamic investigations prior to pelvic organ prolapse surgery when there are urinary symptoms or occult urinary incontinence {Grade C}.
Abstract: We report a case of acute urinary retention with meningoradiculoneuritis resulting from coinfection with varicella-zoster virus (VZV), HIV, and hepatitis B virus (HBV). The case is discussed in the context of other neurological syndromes associated with VZV and HIV infections, and of other viral causes of acute retention of urine.
Abstract: OBJECTIVE: To characterize the spontaneous contractile activity (SCA) developed by detrusor from patients with neurogenic detrusor overactivity (NDO) because the alteration of detrusor properties plays a critical role in the pathogenesis of detrusor overactivity, as well as to evaluate the role of K(ATP) and K(Ca) channels on this SCA because these channels regulate detrusor SCA in many species, including humans without overactive bladder (OAB). PATIENTS AND METHODS: Human bladder samples were obtained from 44 patients undergoing cystectomy for bladder cancer with no known OAB symptoms and from 38 patients suffering from urodynamically diagnosed NDO. Detrusor strips with or without urothelium/suburothelium were mounted isometrically in organ baths filled with Krebs-HEPES (37 °C; 95% O(2) /5% CO(2) ). Strips were incubated with 10 µm pinacidil (K(ATP) opener) followed by 10 µm glibenclamide (K(ATP) blocker). In another set of experiments, strips were incubated with 30 µm NS-1619 (BK(Ca) opener) followed by 100 nm iberiotoxin (BK(Ca) blocker) or with 100 nm apamin (SK(Ca) blocker). RESULTS: SCA occurred more frequently with larger amplitude and area under the curve in detrusor strips from NDO patients compared to control patients. The presence of urothelium/suburothelium did not significantly modify SCA in either patient population. Pinacidil markedly inhibited SCA of detrusor strips from control and NDO patients. This effect was reversed by glibenclamide. By contrast, NS-1619 followed by iberiotoxin did not elicit any significant changes in SCA from NDO patients, contrary to control patients. CONCLUSIONS: K(ATP) and SK(Ca) channels regulate SCA of NDO patients' detrusor strips. By contrast, BK(Ca) channels are not involved in the regulation of detrusor SCA in NDO patients, whereas they regulate SCA in control patients. These results should be considered in the development of K(+) channels openers for the treatment of NDO. Moreover, SCA observed in vitro should be regarded as an in vitro modelling of human NDO.
Abstract: Study Type - Therapy (retrospective cohort) Level of Evidence 2b OBJECTIVE To assess results and morbidity of the periprostatic insertion of an artificial urinary sphincter (AUS) in adult male patients with a neurogenic bladder. PATIENTS AND METHODS A retrospective study was carried out on 51 adult male patients operated on in four urologic academic wards from April 1988 to January 2008. Among these patients, 31% (16/51) had spina bifida and 69% (35/51) had spinal cord injury. All patients suffered urinary incontinence secondary to sphincteric deficiency, and this was associated with detrusor overactivity in 39% of them (leading in these cases to an added bladder augmentation). Perfect continence was defined as a period of dryness of at least 4 h between two self-intermittent catheterizations (SIC) or spontaneous micturitions, moderate incontinence as nocturnal leakage or need to wear protection once during the day or for stress leakage, while severe incontinence was defined as uncontrollable leakage causing patient discomfort. RESULTS Mean age at the procedure was 35 years (18-58). Mean follow-up was 83 months (CI 95%, 65-101). At the end of the study, 15 patients (29.4%) were lost to follow-up. One patient (2%) died shortly after the procedure from a pulmonary infection. Post-operative morbidity was observed in 19% (10/50) of the patients (8 urinary tract infection, 1 failure to perform SIC, 1intracranial hypertension). Of the patients in our study 74% had perfect or moderate continence with a working AUS after a 10-year follow-up CONCLUSIONS We present a specific study on adult patients with a neurological lesion leading to bladder dysfunction treated by a periprostatic AUS. This procedure was effective in restoring urinary incontinence in the vast majority of our patients with an acceptable morbidity.
Abstract: BACKGROUND: Botulinum toxin type A (BoNTA) has been reported to be effective for treatment of patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergic agents. However, in most of the studies, the efficacy was associated with concomitant use of anticholinergics. OBJECTIVE: To evaluate the efficacy and tolerability of BoNTA and compare two different doses in patients with NDO without concomitant anticholinergics. DESIGN, SETTING, AND PARTICIPANTS: Between 2004 and 2006, adults with NDO refractory to anticholinergics or discontinued anticholinergics due to adverse events or contraindications from four different French clinical centres were included in a prospective, randomised, double-blind, comparative trial. Inclusion criteria were urinary incontinence (UI) resulting from NDO that could not be managed with anticholinergics. Patients with bladder cancer, lithiasis, or urinary infection were excluded. INTERVENTION: Patients were randomised to receive an intradetrusor injection of 500 U or 750 U of BoNTA. MEASUREMENTS: The initial evaluation (ie, clinical and urodynamic variables and quality of life [QoL]) was repeated at days 30, 90, 180, and 360. Primary outcome was complete continence rate at day 30. Secondary outcomes were cumulative incontinence rate, reappearance of leakages, pad usage, urodynamics, and QoL. RESULTS AND LIMITATIONS: Seventy-seven patients received 500 U (n=39) or 750 U (n=38) of BoNTA and were included in the full analysis set for efficacy analysis. Complete continence at day 30 was observed in 22 patients (56.4%) and 28 patients (73.7%) receiving 500 U or 750 U of BoNTA, respectively (p=0.056; one-sided chi(2) test to compare to alpha=0.025). The median delay in the reappearance of leakages was 168 d. Monotherapy of BoNTA significantly improved UI in patients with NDO. Although there was a trend towards a greater improvement with 750 U of BoNTA, no statistically significant differences in terms of clinical and urodynamic variables and QoL were found between the treatment groups. Tolerability was excellent and equivalent for both doses. CONCLUSIONS: Monotherapy of BoNTA at Dysport (Ipsen, Brisbane, CA, USA) doses of 500 U or 750 U seems to be effective and well tolerated in patients with NDO.
Abstract: BACKGROUND: The current diagnostic criteria of urinary tract infection (UTI) in male patients with spinal cord injury (SCI) are not clear. METHODS: The authors studied 381 episodes of "symptomatic" UTI (209 participants) and 277 episodes of "asymptomatic" UTI (205 participants) in male SCI patients using intermittent catheterization. UTI was defined as a bacterial count ≥10(2) colony-forming units (cfu)/mL (American Paraplegia Society criterion). Univariate analysis and receiver operating characteristic (ROC) curve analysis were used to determine optimal cfu and white blood cell (WBC) thresholds. RESULTS: The most prevalent clinical signs, alone or in combination, were cloudy and/or malodorous urine (51.4%), onset of urinary incontinence (51.2%), fatigue (41.7%), fever (30.7%), and increased spasticity (30.2%). Urine cfu and WBC levels in patients with only one sign, including fever, were not significantly higher than those in asymptomatic controls. WBC, but not cfu, levels increased significantly with the number of signs (P = .026). Univariate analysis and ROC curve analysis failed to identify cfu, WBC, or a combination of cfu and WBC count thresholds, allowing discrimination between the symptomatic and asymptomatic UTI groups. CONCLUSIONS: Clinical signs of UTI correlate poorly with the urine cfu and WBC levels in SCI patients, except for a positive relationship between WBC counts and the number of signs. Fever alone has no higher diagnostic value. There are no satisfactory cfu and WBC thresholds: thresholds more restrictive than the current American Paraplegia Society criteria provide higher specificity values but with equivalent loss of sensitivity.
Abstract: Study design:Case series from a prospectively acquired database and phone survey.Objectives:To assess the efficacy of upper limb reanimation (ULR) protocols on acquisition of intermittent self-catheterization (ISC) in C5-C7 ASIA tetraplegic patients.Setting:University Hospital, Paris, France.Methods:A prospectively acquired database of 152 tetraplegic patients followed in ULR consultation between 1997 and 2008 in a rehabilitation unit was studied. A total of 20 patients met the inclusion criteria, which mainly were traumatic C5-C7 tetraplegic adult patients who were unable to perform ISC, and who benefited from ULR with the objectives of improving hand abilities and of ISC acquisition, through urethral orifice for males or via a continent urinary stoma for females. The main outcome measure was ISC acquisition (ISC+) proportion. Population characteristics and secondary outcome measures: ISC+/ISC- patients were compared regarding epidemiological and surgical data, key-grip strength, patient global improvement score, activities of daily living and quality of life (PGI-I, Wuolle questionnaire, verbal rating scale).Results:ISC+ was 75%. It depended on key-grip strength (P<0.05) and led to a statistically significant improvement of urinary status compared with ISC- patients (P<0.01). ULR improved patients' abilities and QoL in both ISC+ and ISC- patients.Conclusion:ULR protocols allow ISC in most C5-C7 tetraplegic patients. Multidisciplinary care with surgeons and PRM physicians improves patients' vital and functional prognosis by changing their urological-management method.Spinal Cord advance online publication, 28 September 2010; doi:10.1038/sc.2010.120.
Abstract: To present a comprehensive approach to the assessment of the severity of the autonomic lesion in spinal cord injury (SCI) patients, with regard to the level of lesion. To discuss how to assess an isolated sympathetic spinal cord that has lost supraspinal control (sympathetically complete lesion).
Abstract: The increasing body of evidence and number of potential indications for the use of botulinum neurotoxins (BoNTs) in the lower urinary tract (LUT) underlines the pressing need for evidence-based guidelines.
Abstract: Pregnancies in spinal cord-injured (SCI) patients present unique clinical challenges. Because of the neurogenic bladder and the use of intermittent catheterization, chronic bacteriuria and recurrent urinary tract infection (UTI) is common. During pregnancy the prevalence of UTI increases dramatically. Recurrent UTI requires multiple courses of antibiotics and increases the risks of abortion, prematurity, and low birth weight. A weekly oral cyclic antibiotic (WOCA) program was recently described for the prevention of UTI in SCI patients.
Abstract: Urinary symptoms are frequent in case of neurologic diseases, symptoms depends on the pathology as well as the extend and the location of the disease. Initial evaluation includes clinical, biological, urodynamic and radiologic assessment in order to precise symptoms quality of life and risk factors of medical complications. Treatment efficacy, adaptation to incapacities, evolution of the disease and complications require close follow up specially in the spinal cord injury and myelomeningocele population. Multidisciplinary approach is often required to optimise treatment strategy.
Abstract: Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).
Abstract: To study the value and efficacy of botulinum toxin for treatment of cases of non-neurogenic detrusor overactivity (NNDO) that are refractory to anticholinergic drugs.
Abstract: Botulinum toxin A intradetrusor injections have revolutionised the treatment of neurogenic detrusor overactivity. Based on a systematic literature review, the french speaking group of neuro-urology (Genulf) propose clinical guidelines concerning the indications of the first injection.
Abstract: Neuroanatomical and lesion studies have identified lumbar spinothalamic (LSt) neurons to be essential for ejaculation, but their precise role remains elusive.
Abstract: This systematic literature review discusses the efficacy and safety of botulinum toxin type A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).
Abstract: For many years peripheral electrical stimulation has been performed to treat urinary tract dysfunction in neurogenic patients. Numerous methods have been used, involving sacral roots as peripheral nerve and pelvic organs. All of them are not valuable today. Sacral neuromodulation, tibial posterior and pudendal nerve stimulation have been successful for treatment of neurogenic detrusor overactivity in the short/middle term. Methods and respective interest of the main procedures will be discussed.
Abstract: The involvement of the neuropeptide oxytocin in the control of male sexual responses is documented although its exact mechanisms of action, and especially the site(s) of action, are not fully delineated. In order to clarify this issue, we tested the effects of a peptide oxytocin antagonist delivered through different routes on sexual responses elicited, in anaesthetized male rats, by i.c.v. 7-hydroxy-2-(di-N-propylamino) tetralin (7-OH-DPAT), a dopamine agonist, preferentially active on D3 receptors.
Abstract: To determine whether intermittent positive-pressure breathing (IPPB) improved lung compliance, work of breathing, and respiratory function in patients with recent high spinal cord injury (SCI).
Abstract: To characterize the effect of acute unilateral and bilateral lesion of the pelvic and pudendal nerves, and nerves innervating the iliococcygeous and pubococcygeous muscles during sneezing in anaesthetized female cats, on intravesical pressure (IVP), urethral pressure (UPs) and external urethral sphincter (EUS) activity.
Abstract: Injections of botulinum toxin into the detrusor is a major evolution for treatment of neurogenic bladder. They are now considered as a treatment of choice, safe and efficient, in refractory neurogenic overactivity in catheterized patient. To date, there are no consensual practical guidelines for the follow-up of patients having been treated by intradetrusor botulinum toxin, whatever the indication of the treatment, functional, that is, for improving continence and overactive bladder syndrome or organic, that is, for treatment of high-detrusor pressure and their deleterious impact of urinary tract. This lack of guidelines leads to heterogeneity of treatment management and limit the definition of optimal modalities of intradetrusor botulinum toxin treatment in neurogenic patients. The aim of your work, prepared jointly with the International Francophone Neuro-Urological expert study group (GENULF), aimed at putting forward well-informed specific recommendations for the follow-up of patients having been treated by intradetrusor botulinum toxin for functional or organic indication of neurogenic detrusor overactivity.
Abstract: To evaluate the impact of botulinum toxin type A (BoNTA) on health-related quality of life in patients with neurogenic urinary incontinence (UI) using the Incontinence Quality of Life questionnaire (I-QOL).
Abstract: The life expectancy of spinal cord injury patients has increased considerably over recent years due to improved management based on a better understanding of the pathophysiology of the abnormalities induced by spinal cord injury. The objective of treatment of spinal cord injury patients is to prevent the various complications, but also allow patients to regain maximum independence in order to facilitate their social rehabilitation. This result can only be obtained and maintained by multidisciplinary management in a network including urologists, as, although urinary complications have considerably decreased (they no longer represent the leading cause of mortality), they still constitute a frequent presenting complaint or reason for rehospitalization in this population.
Abstract: To assess the reliability, validity, responsiveness, and minimally important difference (MID) of the Incontinence Quality of Life (I-QOL) questionnaire in patients with urinary incontinence due to neurogenic detrusor overactivity.
Abstract: Synchronized activation of autonomic and somatic divisions of the nervous system respectively destined to the seminal tract, including the bladder neck and the pelvi-perineal striated musculature, is necessary for anterograde ejaculation. We aimed at investigating the role of intermesenteric nerves (IMNs) in ejaculation in anesthetized rats. Electrical stimulation of intact IMNs and distal and proximal stumps of the sectioned IMN were tested in isoflurane-anesthetized male rats. Electrical stimulation of the intact IMN was also applied to rats with acute spinal transection at the T8 level. The effects of IMN electrical stimulation on emission and expulsion phases of ejaculation were evaluated by measuring seminal vesicle pressure (SVP) and bulbospongiosus (BS) muscle contractions, respectively. IMN electrical stimulation could induce SVP increase and rhythmic contractions of BS muscle concomitantly with expulsion of the seminal plug. When compared with intact IMN electrical stimulation, the occurrence of ejaculation and rhythmic BS muscle contractions, but not SVP increase, was reduced in response to electrical stimulation of the distal stump of the sectioned IMN. In comparison to intact IMN electrical stimulation, the occurrence of ejaculation and rhythmic BS muscle contractions was not significantly modified, whereas the increase in SVP was diminished when the proximal stump of the sectioned IMN was stimulated. Spinalization abolished ejaculation and rhythmic BS muscle contraction but did not impair SVP increase. It is concluded that both afferents conveyed by IMN and relaying supraspinally and efferents of IMN are involved in IMN electrical stimulation-induced ejaculation. We propose that the IMN electrical stimulation paradigm can be used to investigate physiological and pharmacologic aspects of ejaculation.
Abstract: In addition to serotonin, dopamine within the CNS is known to play a primary role in the control of ejaculation. However, whether D(2) and/or D(3) dopamine receptor subtypes mediate this effect is still unclear. In order to clarify this issue, a pharmacological competitive study using the preferential D(3) agonist 7-hydroxy-2-(di-N-propylamino)tetralin (7-OH-DPAT) alone or in combination with competitive nonpreferential or preferential D(2) and D(3) antagonists delivered intracerebroventricularly (i.c.v.) was undertaken in anesthetized rats. Urethane-anesthetized male rats were implanted into the cerebral ventricle with a cannula for i.c.v. injections, and recording electrodes were placed within the bulbospongiosus (BS) muscle to monitor BS muscle contractions, which were used as a marker for the expulsion phase of ejaculation. Following i.c.v. injection, 7-OH-DPAT induced ejaculation and rhythmic BS muscle contractions. Co-injected i.c.v. with 7-OH-DPAT, the nonselective D(2)/D(3) antagonist (raclopride), and the preferential D(3) antagonist (S(-)-N[n-butyl-2-pyrrolidinyl)methyl]-1-methoxy-4-cyanonaphtalene-2-carboxamide; nafadotride) but not the preferential D(2) antagonist ((+/-)-3-[4-(4-chlorophenyl)-4-hydroxypiperidinyl]methylindole; L 741,626) inhibited the occurrence of ejaculation and BS muscle contractions. These results suggest that i.c.v. delivery of 7-OH-DPAT does represent a pertinent model to investigate the physio-pharmacology of ejaculation. It is inferred that targeting brain D(3) receptors may provide a therapeutic approach for treating ejaculatory disorders in humans.
Abstract: The aim of the study was to determine whether dapoxetine, a short-acting selective serotonin reuptake inhibitor, acts at the spinal or supraspinal level to inhibit the ejaculatory reflex.
Abstract: Detrusor smooth muscle relaxation is mainly mediated by the cyclic adenosine monophosphate (cAMP) pathway. Elevation of cAMP levels by phosphodiesterase type 4 (PDE4) inhibition relaxes smooth muscles of various origins. We aimed to determine the effect of a PDE4 inhibitor, rolipram, on human detrusor contractions.
Abstract: Historically, impaired renal function was the leading cause of death in spinal cord injury patients. Although the management of these patients has considerably improved due to progress in functional rehabilitation and neurourology, renal failure remains a significant cause of morbidity in this population. In this article, the authors review and classify the diagnostic tools able to detect urological changes likely to induce irreversible impairment of renal function. Based on a review of the recent literature, they define the incidence of renal impairment (morphological or function) in spinal cord injury patients and describe the main risk factors for deterioration of renal function in these patients.
Abstract: Sensory impulses derived from the bladder and urinary sphincter system play an important role in the control of detrusor-sphincter function. Conscious sensation is essential to ensure the storage phase and to allow micturition at a functionally and socially acceptable time. Adequate sensation of the lower urinary tract requires an intact urothelium--peripheral nervous system--spinal cord--brain stem--midbrain--sensory cortex axis. This article reviews the current anatomical, physiological and pathophysiological knowledge concerning the afferent (sensory) nerve pathways of the bladder and urethra, with particular emphasis on their physiological and therapeutic implications.
Abstract: The management of sexual dysfunction has been revolutionized over recent years with the arrival of new treatments for erectile dysfunction. In parallel, groups specialized in neurosexology have gradually emerged in order to improve the patient's fertility. This article presents the disorders most frequently encountered in spinal cord injury and the main approaches to management.
Abstract: During stress-induced increase in abdominal pressure, urinary continence is maintained by urethral closure mechanisms. Active urethral response has been studied in dogs and rats. Such an active urethral response is also believed to occur in humans during stress events. We aimed to investigate urethral closure mechanisms during sneezing in cats. Urethral pressures along the urethra (UP1-UP4), with microtip transducer catheters with UP4 positioned in the distal urethra where the external urethral sphincter (EUS) is located, and intravesical pressure were measured, and abdominal wall, anal sphincter (AS), levator ani (LA), and EUS electromyograms (EMGs) were recorded during sneezing under closed-abdomen and open-abdomen conditions in eight anesthetized adult female cats. Proximal and middle urethral response induced by sneezing was not different from bladder response. Distal urethral response was greater compared with proximal and middle urethral and bladder response. In the open-abdomen bladder, proximal and middle urethral responses were similarly decreased and distal urethral response was unchanged compared with the closed-abdomen bladder. Bladder and urethral responses were positively correlated to sneeze strength. EUS, LA, and AS EMGs increased during sneezing. No urine leakage was observed, regardless of the strength of sneeze. In cats urethral closure mechanisms are partly passive in the proximal and middle urethra and involve an active component in the distal urethra that is believed to result from EUS and possibly LA contractions. Because central serotonin exerts similar effects on the lower urinary tract in cats and humans, the cat may represent a relevant model for pharmacological studies on continence mechanisms.
Abstract: Vesicourethral dysfunction is very frequent in multiple sclerosis (MS) and has functional consequences for patients' quality of life and also an organic impact following complications of the neurogenic bladder on the upper urinary tract. While the functional impact and its management are well documented in the literature, the organic impact remains underestimated and there are no consensual practical guidelines for the screening and prevention of MS neurogenic bladder complications. The aim of this review of the literature, focused on identifying the risk factors of urinary tract complications in MS, is to put forward well informed considerations to help in the definition of practical guidelines for the follow-up of the neurogenic bladder in MS in order to improve its prevention and patient management. Four main risk factors have been identified for upper urinary tract damage: the duration of MS, the presence of an indwelling catheter, high-amplitude neurogenic detrusor contractions and permanent high detrusor pressure. Detrusor-sphincter dyssynergia, age over 50 and male sex may form three additional risk factors. Recommendations for long-term urological follow-up, taking into account these specific risks are constructed according to the procedures recommended by the French Health Authorities.
Abstract: One of the main complications of spinal cord injury is neurogenic bladder when the bladder fails to empty spontaneously. Urinary tract infection is the leading cause of morbidity and the second cause of mortality in these subjects. Patient education and personalized medical follow-up must ensure adapted management depending on the risk factors and the voiding mode. The risk of urinary tract infection can be decreased by perfect neurological control of detrusor activity combined with a method of drainage: intermittent self-catheterization. Despite these measures, many patients experience recurrent symptomatic urinary tract infections. Repeated antibiotic therapy increases the risk of selection of multiresistant bacteria without reducing either the incidence or the severity of symptomatic urinary tract infections. Asymptomatic bacteriuria is very frequent in patients treated by intermittent catheterization and does not justify antibiotic therapy, as antiseptics and urinary alkalinizers or acidifiers have been shown to be effective. "Antibiocycle" strategies could have a beneficial role by significantly decreasing the number of infections and hospitalizations with no major ecological risks, by using molecules that are well tolerated orally with a low selection pressure. All febrile urinary tract infections require rapid investigation and an urgent urological and infectious diseases opinion (abscess, severe sepsis, resistance). The SPILF-AFU 2002 consensus conference provided answers to major questions concerning the definition, treatment and prevention of nosocomial urinary tract infection, especially in a context of neurogenic bladder.
Abstract: To study repeat intradetrusor botulinum toxin injections for the treatment of neurogenic detrusor overactivity in terms of safety and improvement of continence status and urodynamic parameters.
Abstract: Sphincter dysfunction is an almost constant pathological process in neurourology. No oral pharmacological treatment is available to treat stress urinary incontinence secondary to sphincter incompetence or to relieve urethral hypertonia usually induced by detrusor-sphincter dyssynergia. The few treatments that induce sphincter relaxation are not sufficient to justify a routine therapeutic indication.
Abstract: Intrathecal clonidine has been tested in spinal cord injury patients not supporting or resistant to anticholinergic drugs. Although the acute effect of clonidine on urodynamic parameters was satisfactory, cardiovascular adverse effects limited the long-term efficacy of this treatment. Intrathecal baclofen has a limited effect on overactive bladder in patients with spinal spasticity, but can modify the quality of erections and induce an incapacity to trigger ejaculation by vibratory penile stimulation.
Abstract: Electrostimulation of anterior sacral nerve roots has been gradually developed since the 1970s and now represents a real alternative for the treatment of lower urinary tract dysfunction in neurological patients. In some cases, it can also allow improvement of erections and improvement of defecation. The success of the intervention largely depends on rigorous selection of the patients likely to benefit from this technique. In this article, the authors describe the technical principles of this procedure, the ideal patient profile of candidates for this procedure and the main results that can be achieved.
Abstract: Anal incontinence and gastrointestinal disorders are one of the major causes of impaired quality of life in patients with neurological disease. Patients are very often too embarrassed to spontaneously talk about these problems and problems of chronic constipation can lead to microbial maceration, a known risk factor for urinary tract infection. In this article, the authors review the physiology of defecation and describe the main disorders observed in the various neurological diseases and their management.
Abstract: The management of urinary incontinence in patients with neurological disease is complex. Physicians face a multitude of challenges related to progression of the primary condition, the presence of a diversity of other related and unrelated symptoms, the safety, efficacy and tolerability issues associated with multiple therapies being required and the changing need for collaboration with other specialities.
Abstract: Spinal cord injury (SCI) patients with neurogenic bladder have an increased risk for symptomatic urinary tract infection (UTI). Recurrent UTI requires multiple courses of antibiotic therapy, markedly increasing the incidence of multidrug-resistant (MDR) bacteria.
Abstract: The occurrence of ejaculation, which consists of 2 distinct phases (emission and expulsion), requires a tight coordination of peripheral autonomic and somatic nerves. However, some aspects of the mechanism of ejaculation are not clearly defined. To clarify this issue, we used the p-chloroamphetamine (PCA)-induced ejaculation model in anesthetized rats and investigated the effects of selective peripheral nerves lesions on seminal vesicle and bulbospongiosus (BS) muscle activities as representing physiological markers of emission and expulsion phases, respectively. In intact rats, ejaculation induced with PCA (intraperitoneal 5 mg/kg) correlated with coordinated increases in seminal vesicle pressure (SVP) and BS electromyographic activity. PCA-induced ejaculation was still observed in rats with bilateral lesion of hypogastric nerves (HNx), lumbar paravertebral sympathetic chain (LSCx), or dorsal nerves of the penis (DNPx). Conversely, bilateral section of pelvic nerves (PNx) or L6-S1 dorsal roots (DRx) abolished PCA-induced ejaculation. The amplitude of SVP increases induced by PCA was reduced in PNx, HNx, and LSCx rats, whereas it was unchanged in DRx and DNPx rats. The time interval between SVP increases and BS muscle contractions induced by PCA was comparable in the different neural lesion groups. In conclusion, PCA initiates both emission and expulsion independently from each other. In this model, afferents conveyed by the pelvic nerves appear to be unnecessary for occurrence of BS muscle contractions but are essential for a complete ejaculatory response.
Abstract: To further investigate the rationale for using spinal nerve stimulation (SNS) for treating bladder overactivity associated with cystitis in a rat model of cyclophosphamide-induced cystitis, as several studies suggested that symptoms associated with chronic cystitis could be treated using stimulation of sacral spinal nerves, but the mechanisms by which it works are unknown.
Abstract: To determine the efficacy of the consumption of cranberry juice versus placebo with regard to the presence of in vitro bacterial anti-adherence activity in the urine of healthy volunteers. Twenty healthy volunteers, 10 men and 10 women, were included. The study was a double-blind, randomized, placebo-controlled, and cross-over study. In addition to normal diet, each volunteer received at dinner a single dose of 750 ml of a total drink composed of: (1) 250 ml of the placebo and 500 ml of mineral water, or (2) 750 ml of the placebo, or (3) 250 ml of the cranberry juice and 500 ml of mineral water, or (4) 750 ml of the cranberry juice. Each volunteer took the four regimens successively in a randomly order, with a washout period of at least 6 days between every change in regimen. The first urine of the morning following cranberry or placebo consumption was collected and used to support bacterial growth. Six uropathogenic Escherichia coli strains (all expressing type 1 pili; three positive for the gene marker for P-fimbriae papC and three negative for papC), previously isolated from patients with symptomatic urinary tract infections, were grown in urine samples and tested for their ability to adhere to the T24 bladder cell line in vitro. There were no significant differences in the pH or specific gravity between the urine samples collected after cranberry or placebo consumption. We observed a dose dependent significant decrease in bacterial adherence associated with cranberry consumption. Adherence inhibition was observed independently from the presence of genes encoding type P pili and antibiotic resistance phenotypes. Cranberry juice consumption provides significant anti-adherence activity against different E. coli uropathogenic strains in the urine compared with placebo.
Abstract: To study histological features and morphological differences in bladder wall specimen from patients with and without botulinum toxin A injections and to compare those issues in responders and non-responders to the toxin therapy.
Abstract: This article describes an outbreak of ACC-1-producing Klebsiella pneumoniae involving 40 patients. These were mainly men under 40 years old with a spinal cord injury, in a physical medicine and rehabilitation unit. The main risk factors were prolonged hospital stay, multiple-bed rooms, tracheostomy care and assisted defaecation. The outbreak was only controlled after the introduction of rigorous patient placement (i.e. single rooms or cohorting in the same room), while allowing the patients to have free access to the various technical services (e.g. physiotherapy and occupational therapy) and living spaces necessary for re-education.
Abstract: To prospectively evaluate the effect of pump-infused intrathecal baclofen infusion (ITB) in therapeutic doses on sleep quality and on daytime and nighttime respiratory function in patients with severe spasticity.
Abstract: To investigate the effects of acute intravenous (i.v.) delivery of tamsulosin and alfuzosin on the contractions of bulbospongiosus muscles (BS) induced by central delivery of a serotonin agonist, 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT), in anaesthetized rats, as an experimental model of the expulsion phase of ejaculation.
Abstract: Many studies report the use of alcoholic capsaicin instillation to treat neurogenic detrusor overactivity (NDO) in spinal cord injured (SCI) and multiple sclerosis (MS) patients. However, poor tolerability due to the irritative effect of the ethanol solvent limits its use. Our study aimed to evaluate the efficacy and tolerability of a new formulation of capsaicin in a glucidic solution in a multicenter clinical trial.
Abstract: Patients with neurogenic bladder represent a small fraction of the total overactive bladder population. As a consequence, development of new therapies in this area has largely focused on idiopathic urinary incontinence. The absence of data for patients with neurological disease has far-reaching implications, affecting reimbursement and physicians' willingness to prescribe therapies, and limiting access of potential valuable treatments to patients whose lives are significantly impaired by inadequately managed bladder symptoms.
Abstract: Female rats display a repertoire of behaviors during a sexual encounter with a male, including sexually receptive (the lordosis response) and proceptive (darts and hops, and ear wigglings) behaviors.
Abstract: We describe a large outbreak involving a Klebsiella pneumoniae strain producing a plasmid-encoded ACC-1 type AmpC beta-lactamase in a hospital caring for patients with motor impairment. The epidemic strain was isolated from 57 patients in six wards between September 1999 and May 2003 and caused clinical infections in 19 patients.
Abstract: We report on the case of a patient suffering from Friedreich's ataxia (FA) with very painful and disabling spasms that were improved markedly by intrathecal baclofen infusion. To our knowledge, this is the first report of an intrathecal baclofen-delivering pump implantation in an FA patient.
Abstract: We determined the safety and efficacy of each of 2 doses of botulinum toxin type A (BTX-A) (200 or 300 U BOTOX) injected into the detrusor for urinary incontinence caused by neurogenic detrusor overactivity of predominantly spinal cord origin.
Abstract: The first stages of management consist in explaining the particularities of the treatments for erectile dysfunction, treating the urinary and faecal incontinence, spastic problems, neuropathological pain the neuro-orthopaedic complications. Rehabilitation of the patients consists in teaching them techniques to provoke reflex erections, through the reappropriation of the spared sensitive areas, and how to administer the intracavernous injections themselves.
Abstract: To determine whether a custom girdle, designed to provide truncal stability and abdominal support, will improve pulmonary function, enhance inspiratory muscle activity, and reduce the sensation of respiratory effort in patients with spinal cord injury (SCI).
Abstract: We studied the intermediate-term clinical, urodynamic, endoscopic and radiological efficacy of the Ultraflex urethral stent (Boston Scientific Co., Boston, Massachusetts) for the treatment of detrusor-sphincter dyssynergia (DSD) in spinal cord injured patients.
Abstract: Neurogenic Para-Osteo-Arthropathy (NPOA) occurs as a consequence of central nervous system injuries or some systemic conditions. They are characterized by bone formation around the main joints.
Abstract: The objective of this study was to evaluate the epidemiology of antibiotic-resistant bacteria among motor impaired patients admitted to an acute rehabilitation unit.
Abstract: Bladder compliance is defined by the ratio of the increase of intravesical pressures to the increase of volume (_V/_P). The pathophysiology of disorders of compliance in neurogenic bladder is still poorly elucidated. It can be evaluated in terms of three elements: 1) The natural history of the appearance of these disorders in neurogenic bladders. Clinical experience shows the existence of prognostic factors that determine the development of these disorders, such as the voiding mode adopted (self-catheterization/hetero-catheterization versus indwelling catheter), the level of the spinal cord lesion (suprasacral versus sacral, incomplete versus complete, and cauda equina lesions), and the presence of meningomyelocele. 2). Data derived from conservative management of these disorders in neurogenic bladders: urethral dilatation, various sphincterotomies, bladder disafferentation, alpha-blockers, vanilloids (resiniferatoxin and capsaicin), intra-detrusor botulinum toxin and intrathecal baclofen, have demonstrated a marked improvement of disorders of compliance associated with neurogenic bladder 3). Data derived from experimentations. Morphometric studies on animal or human bladder strips have demonstrated an increased expression of proteolytic enzymes and endogenous tissue inhibitors of metalloproteinases (MMP-1) and type III collagen mRNA in hypocompliant neurogenic bladders. Reduction of bladder wall blood flow, bilateral section of hypogastric nerves in rats, study of the bladders of spinalized rats, and reduction of oestrogenic hormone impregnation, show that these conditions induce loss of the viscoelastic properties of the bladder With the arrival of new treatments, active on afferent and/or efferent pathways or even on the central nervous system, it is very important to further our understanding of the pathophysiology of disorders of compliance in neurogenic bladders. Reversibility of these disorders constitutes a major therapeutic challenge and its functional consequences make it a critical prognostic factor for the outcome of neurogenic bladder
Abstract: Multiple dramatic consequences follow medullary lesions. Not only are voluntary motor control and sensitivity of the body segment below the lesion lost, but it also becomes impossible to control erection and ejaculation as well as urinary and faecal continency. The first investigations into genito-sexual function in paraplegics have brought about the idea, commonly admitted in the medical world, that this kind of patient is impotent and sterile. Fortunately this idea is disappearing gradually and many data have demonstrated that appropriate treatment is required and some therapies efficient. This is particularly important in the case of the population concerned, namely young men in 70% of the cases, since the usual age bracket at trauma is between 25 and 35 years old. At this time of life, sexual activity is often at its peak, so that the fertility potential becomes erased.
Abstract: We investigated the possibility that a change in transmission in group II pathways contributes to the spasticity of patients with spinal lesions. Thirteen patients were tested by measuring the quadriceps stretch reflex (Ashworth scale), the threshold of the quadriceps H reflex, and the oligosynaptic facilitation of the quadriceps H reflex elicited by volleys to groups I and II afferents in the common peroneal nerve (CPN). All these tests were performed before and after intrathecal injection of clonidine (60 microg). Early group I CPN-induced excitations occurred in 13 patients, and late group II CPN-induced excitations in 12. Both facilitations were, on average, significantly greater than those reported for normal subjects, but these increases were not correlated with the clinically assessed spasticity. Clonidine caused a constant, prolonged and dramatic decrease in spasticity, but did not alter the threshold of the quadriceps H reflex. CPN-induced group I and group II non-monosynaptic excitations of quadriceps motoneurones were significantly decreased, although they did not return to normal values. These results provide a further indication that group II pathways gives rise to the heteronymous late CPN-induced excitation. The pathophysiological role of a change in transmission in group II pathways in spasticity is discussed.
Abstract: Intrathecal clonidine was tested for the control of bladder hyperreflexia resistant to pararsympathicolytic drugs in spinal cord injured patients. Urodynamic parameters were significantly improved after acute bolus of intrathecal low doses of clonidine. Unfortunately, the chronic intrathecal infusion of clonidine induced cardiovascular side-effects. Intrathecal baclofen did not modified significantly neurogenic bladder dysfunction from spinal lesion. But intrathecal baclofen modified penile erection quality and impaired the ejaculation reflex induced by penile vibratory stimulation in the same population.
Abstract: We report two patients presenting with a subacute right hemisphere stroke. These cases demonstrate a double dissociation between unilateral neglect and anosognosia for hemiplegia. The first patient suffered from a severe left hemiplegia associated with severe and persisting unilateral neglect. He appeared fully aware of his motor impairment. The second patient had a severe left hemiplegia, without any major sign of unilateral neglect on clinical tests nor on behavioural assessment. Nevertheless, he presented a severe and sustained anosognosia for hemiplegia. These case reports support the assumption that anosognosia and unilateral neglect, although they are frequently associated, may rely on independent mechanisms.
Abstract: The purpose of this study was to assess urodynamics parameter changes induced by acute sacral neurostimulation (SNS) in spinal cord injury (SCI) patients with neurogenic detrusor hyperreflexia. Fourteen SCI patients with urge incontinence owing to a hyperreflexive bladder were prospectively evaluated. Neurostimulation was performed on the root that obtained the best motor response (10 Hz, 210 microseconds) and amplitude ranges of >0 to 10 V. The urodynamics study was done in the prone position. Four cystometries were recorded before (two), during (one), and 10 minutes after stimulation (one). Maximal bladder capacity (MBC) (volume to first leakage), bladder volume at first uninhibited contraction (BV(1stC)), and maximal detrusor pressure during uninhibited contractions (P(det)max) were compared. Left S3 foramen was the most commonly used (9/14). Mean amplitude of stimulation was 4.5 V (range, 0.5-8.5 V). Statistically significant differences (Mann-Whitney U-test) were found for MBC, BV(1stC), and P(det)max with mean variations of +206.8 mL (+107%, P < 0.001), +151.5 mL (+98%, P < 0.01), and -23.4 cm H2O (-27%, P < 0.05), respectively. Patient gender and SCI level did not reveal any difference. Patients who reached a MBC of up to 400 mL (+278.2 mL, +129%, n = 10) with SNS had statistically significant improvement of BV(1stC) (+210.2 mL, +125%, P < 0.01) and P(det)max (-33.3 cm H2O, -38%, P < 0.01). Acute temporary SNS in SCI patients has a profound effect on key urodynamics parameters. These neurologically impaired patients with detrusor hyperreflexia may be appropriate candidates for implantable SNS.
Abstract: Pudendal neuropathy is an unusual but important complication of orthopedic surgical procedures involving traction on the fracture table. We describe the clinical and electrophysiological features in six patients presenting with perineal sensory disorders and sexual dysfunction following surgical repair of femoral fracture, hip dislocation, or intra-articular foreign body, in which the traction table was used. All underwent electrophysiological recordings: bulbocavernosus muscle electromyography (EMG), measurements of the bulbocavernosus reflex latencies (BCRLs), somatosensory evoked potentials of the pudendal nerve (SEPPNs), sensory conduction velocity of the dorsal nerve of the penis (SCVDNP), and pudendal nerve terminal motor latencies (PNTMLs). Signs of denervation localized to the territory of the pudendal nerve were found in 3 patients, normal BCRL in 6, abnormal SEPPNs in 4, and abnormal SCVDNPs and PNTMLs in all cases. The outcome at 2-year follow-up was good, except in one patient with initially unrecordable PNTML. Perineal electrophysiological examination can thus confirm the pudendal neuropathy and give prognostic information.
Abstract: To assess the feasibility of a temporary urethral stent through the striated sphincter in patients in the early phase (before 6 months) of spinal cord injury (SCI) in a department of neurological rehabilitation.
Abstract: Intrathecal clonidine is a powerful antispastic drug. Its mechanism of action is more selective than baclofen. The acute effects are reviewed. An assessment of side effects of clonidine during chronic infusion is needed.
Abstract: The objective of this study was to assess the feasibitity, technical data and use of intrathecal catheter implantation with subcutaneous port for clonidine test injections and individual evaluation.
Abstract: To assess the technique, efficacy and complications of the Ultraflex urethral stent (Boston Scientific Corp., Boston, MA) for the treatment of detrusor-striated sphincter dyssynergia (DSD).
Abstract: Only a few surgical treatments are available for male urinary stress incontinence and artificial urinary sphincter remains the reference treatment. It is associated with a certain morbidity and specific technical limitations and can therefore not always be used in a given patient. Stimulated graciloplasty could constitute a useful alternative treatment in exceptional situations. The objective of this study was to review the technique, the indications already defined apart from urinary incontinence and the results of stimulated graciloplasty in urology.
Abstract: We assess clinical and urodynamic results of sacral nerve stimulation for patients with neurogenic (spinal cord diseases) urge incontinence and detrusor hyperreflexia resistant to parasympatholytic drugs.
Abstract: The purpose of this study was to determine the clinical correlates of supratentorial ventricular dilations and of corpus callosal atrophy at the subacute stage after a severe closed-head injury (CHI). Thirty-three CHI patients underwent MRI 2 months or more after injury. Morphometric measures were compared to clinical data (coma score, coma duration and Glasgow Outcome Scale). There were numerous significant correlations between clinical data and mid-third ventricle and frontal horns measurements. Fewer significant correlations were found with the lateral ventricle bodies and the corpus callosal body. There was no significant correlation with the posterior part of the corpus callosum and of the ventricles. Corpus callosum atrophy correlated significantly with anterior and deep ventricular dilatation. In conclusion, the best indicator of clinical status was ventriculomegaly, and particularly third ventricle enlargement, which probably reflects the extent of both anterior and deep white matter lesions.
Abstract: Neuropharmacology is a rapidly expanding field due to the regular discovery of new neurotransmitters or neuroreceptors. Hopes have now been raised for the treatment of vesicosphincteric disorders by developing molecules with a potential selective clinical action on the detrusor or the urethra. After a brief review of the neuroanatomy and general neuropharmacology of the sympathetic nervous system, the current indications for alpha agonists are reviewed and discussed. These indications include the treatment of priapism, retrograde ejaculation, and incontinence due to sphincter incompetence. The more recent use of agents with a central mechanism of action is also discussed (detrusor hyperactivity of spinal cord injury patients). The authors review the current indications and note that, although the use of these drugs is very specific and limited in the field of urology, it is nevertheless based on an interesting concept. Like molecules at the stage of clinical trials for peripheral or central targets, the mechanism of action of these molecules on the sympathetic adrenergic system needs to be more fully elucidated. Their adverse effects remain the limiting factor for use on peripheral targets.
Abstract: There are several methodological difficulties in the assessment of the effectiveness of rehabilitation in stroke patients. Obviously, double-blind studies are not possible, and only single-blind procedures can used. It is difficult to control for non specific effects, such as spontaneous recovery, patient's and therapist's motivation, social environment. It is necessary to assess the effect non only at the level of impairments, but also on disability and handicap. However, there are now accumulating data in the literature suggesting that stroke rehabilitation has a significant, although mild, effectiveness. Patients treated in specialized stroke rehabilitation units obtain a better outcome, in terms of independence in daily-life activities, than those treated in general wards. They also have shorter hospitalisation durations and are more frequently able to return home. Treatment effectiveness is related to intensity and duration of rehabilitation, and also to stroke severity. Patients with moderate impairments seem to benefit more from treatment than patients with mild or severe deficits. However, significant improvements can still be obtained in very severe cases, and even late (up to two years) post stroke. Similarly, rehabilitation of cognitive deficits (aphasia and unilateral neglect) has also been found efficient in most studies, even if the beneficial effect is relatively small. Aphasic patients treated by speech therapists improve more than patients treated by non specialized therapists or by family members who received a short training. One limitation of neglect rehabilitation is the inconsistent generalisation of treatment effects to daily-life situations. These data are encouraging but further research is needed to find out what precisely works, and how, in the "black box" of rehabilitation.
Abstract: Ten patients presenting agitation and anger outbursts at various stages following a severe closed head injury, were treated in a prospective open trial with carbamazepine, with doses ranging from 400 to 800 mg per day, during 8 weeks. Group analysis demonstrated a statistically significant improvement of a score made up from six target items from the neurobehavioural rating scale. Improvement mainly concerned irritability and disinhibition. A statistically significant improvement was also found with the Agitated Behaviour Scale. Social functioning, as assessed by family or staff ratings of the Katz Adjustment Scale, also significantly improved. No modification of global cognitive functioning was found with the Mini Mental Status Examination. Individual analysis demonstrated that the beneficial effect was important in five cases, moderate in three patients and negligible in two cases. It is concluded that carbamazepine might help to reduce agitated behaviour in brain-injured patients. However, response to treatment demonstrated an important inter-individual variability.
Abstract: Twenty patients were operated upon for heterotopic ossification around the elbow of neurogenic origin following intra-cranial trauma between 1993 and 1997. They did not receive any diphosphonates or radiotherapy. Pre-operative evaluation included a CT scan with enhancement using a dye injected intravenously and 3D reconstruction. Surgery was indicated in the presence of a clinical deficit in mobility or signs (clinical or electrical) of nerve compression. The average delay between the accident and the surgery was 34 months (5 months to 9 years). Associated procedure included lengthening of the brachialis (4 cases), lengthening of the triceps tendon (4 cases) and an anterior capsulotomy in 3 cases. 24 elbows were reviewed with an average follow-up period of 18 months (6 months to 4 years). In 58% of the cases, the result was very good (gain in mobility > 70%) while in the remaining 42% of cases, the improvement was between 40% and 70%. This study confirms the possibility of obtaining good results by excision of the masses of heterotopic ossification of neurogenic origin around the elbow before 1 year after the accident without the necessity of complementary treatment.
Abstract: We assessed the urodynamic effect of various doses of intrathecal clonidine on refractory detrusor hyperreflexia in spinal cord injured patients.
Abstract: Interactions of physical, emotional, cognitive and behavioural impairments after severe closed head injury (CHI) remain poorly understood. A 47-year-old man was referred to our department 13 months after a severe CHI. He demonstrated severe left hemiplegia and disabling orthopaedic complications (left hip infectious arthritis, after surgical treatment for heterotopic ossification). His hip was blocked and extremely painful. He was totally dependent for daily-life activities (Functional Independence Measure (FIM) score = 18). Moreover he exhibited severe cognitive and behavioural troubles, which had been stable for many months beforehand, e.g. complete disorientation for time and place, major memory disorders, agitation, anxiety, depression, irritability, disinhibition, aggressiveness and lack of initiative. Pain disappeared within a few weeks after treatment. Progressively, functional improvement occurred (sitting position, transfers, walking between parallel bars). The FIM score increased to 63. Aggressiveness, irritability and agitation disappeared. Surprisingly, neuropsychological assessment demonstrated parallel improvement of cognitive functions, especially in regard to orientation, and to a lesser degree attention and memory. Such an observation should encourage use of active treatment of physical disabilities, even in patients presenting with an apparently poor cognitive prognosis at a late stage of severe CHI.
Abstract: Two hundred and twenty-five patients with multiple sclerosis and bladder dysfunction were evaluated. 72% had urinary incontinence, 46% dysuria and 24% urinary retention. Detrusor hyperreflexia was the most common finding on cystometry (70%) and 9% of patients had areflexia. Coaxial needle electromyography was performed on all patients and 82% had detrusor-sphincter dyssynergia. Cortical evoked potentials following stimulation of the pudendal nerve were delayed in 72% and sacral evoked latency in 16% especially in patients with incontinence secondary to overactive bladder (25%), suggesting a conus medullaris lesion in these cases. Urologic complications were noted in 40%, with benign lesions in 24% (diverticula, urinary infections) and serious lesions in 16% (hydronephrosis, pyelonephritis, renal reflux). The most common treatment was anticholinergic drugs (efficacy in 92%), alphablockers agents (efficacy in 60%) and autocatheterism in 28%.
Abstract: The progressive denervation of the striated pelvic sphincter musculature is due to repeated stretch injury of the innervation of these muscles when the pelvic floor diaphragm is weak. Electromyography examination, evoked potentials and perineal nerve motor latency confirmed perineal neurogenic abnormalities. This real "perineal stretch neuropathy" can be determine stress urinary incontinence, fecal incontinence and sexual disorders. Rehabilitation therapy may be tried in the treatment of the neuropathy.
Abstract: The bulbocavernosus reflex (BCR) was evaluated before, during and after micturition in 35 patients. All the 19 patients with upper motor neuron lesions had a positive BCR during micturition. By comparison, 11/16 of the patients with a lower motor neuron lesion or with urogynecologic diseases did not have a BCR during micturition. The persistence of BCR during voiding seems to be a loss of central inhibition and maybe represent a good sign of upper motor neuron bladder dysfunction.
Abstract: Eighteen women who had urinary stress incontinence were studied to find the existence of urethral fatigue on effort by using a sphincterometric technique. Urethral pressure measurements at rest as compared with after six heavy coughs showed a mean lowering of the urethral pressure of 40% (range 24.5%-90%) in 10 women. Spectral analysis of the electromyographic trace of the striated urethral sphincter at rest and then after coughing confirms that the striated muscle and the periurethral tissues are involved with a marked quantitative lessening of electric sphincter activity. The clinical, physiopathological, prognostic and therapeutic consequences of this new concept are discussed, together with their relationship to other active forces involved in continence.
Abstract: Continence in women, ensured by a constantly positive urethral closing pressure, is the result of two phenomena: purely passive factors (urethral pressure and compliance, transmission of bladder pressure to the urethra) and active factors mediated by a voluntary and reflex neuromuscular mechanism (contraction, reflexivity, sphincter endurance). In order to define these active forces of continence, we simultaneously studied the quantitative electromyographic activity of the striated sphincter and the bulbocavernosus muscle and variations in the urethral and vesical pressure under various conditions (rest, coughing, stimulation of the pudendal nerve). During coughing, the urethral pressure peak occurred earlier (100 milliseconds) than the vesical peak, associated with hypertransmission of 20%, the bulbocavernosus muscle contracted first, followed by contraction of the striated urethral sphincter (150 ms delay) and this electrical activity preceded the rise in vesical and urethral pressures. Stimulation of the pudendal nerve eliminated the possibility of an artefact related to coughing and induced the same sequence of events.
Abstract: Disorders of the vesico-sphincteral system are due to multiple causes (urological, gynaecological, neurological, psycho-behavioural, iatrogenic) which may be associated. By providing information on the type and evolution of these disorders and on the circumstances in which they developed, questioning is fundamental for the diagnosis. Completed by physical examination, it must precede all exploratory methods, including urodynamic, electrophysiological and radiological examinations. It allows these examinations to be graded and, compared with the results, it gives a better understanding of the physiopathology and aetiology of micturition disorders and therefore ensures their better treatment.
Abstract: Eight cases of vesico-sphincteric disorders (dysuria and chronic retention of urine) observed after spinal anaesthesia are reported. These symptomatic disorders were caused by a peridural haematoma in 3 cases and by lack of bladder contraction due to an "exhausted detrusor muscle" in 5 cases. The mechanism of the disorders (predominant vesical hypoactivity with sensory disorders) is discussed. The usefulness of urodynamic investigation in determining the physiopathological mechanism(s) and that of electrophysiological exploration in the search for a neurogenic disease is emphasized, as is the need for a preventing treatment (intermittent catheterization) in case of forced bladder detected by systematic recording of postoperative micturitions.
Abstract: Results of flowmeter studies in 145 patients before and then immediately after urodynamic exploration were unchanged in 80% of women and 72% of men. Abnormal results on flowmetric examination, detected in 18% of cases prior to urodynamic studies, were assessed as normal during follow-up urodynamic tests. These findings raise the question of the validity of flowmeter parameters determined during urethrocystometric exploration.
Abstract: For many years, perineal neurogenic abnormalities associated with stress urinary incontinence have been described using electromyography examination, evoked potentials or neuromuscular biopsy. It has been suggested that the progressive denervation of the striated pelvic sphincter musculature that occurs in genuine stress incontinence is due to repeated stretch injury of the innervation of these muscles when the pelvic floor diaphragm is weak. New investigations such as perineal nerve motor latency confirmed this hypothesis. A real "perineal stretch neuropathy" may be described. It is very important to know about this neurogenic factor before considering rehabilitation therapy.
