Biochemical changes in denervated muscle identified by magnetic resonance spectroscopy

The significance of the ASIA (American Spinal Injury Association) scores and SSEP (somatosensory evoked potentials) recordings in predicting the recovery of bladder function was evaluated in 70 patients with acute, traumatic spinal cord injury (SCI). The patients were examined following admission to the rehabilitation centre (mean 10 days post-trauma) both clinically by the ASIA scores and electrophysiologically by tibial and pudendal SSEP recordings. The results of the initial examinations were related to the degree of recovery of bladder function of the patients assessed by urodynamic examination at the end of the rehabilitation programme (at least 6 months post-trauma). The recovery of somatic nerve function (external urethral sphincter function) involved in bladder function was correlated to both the initial ASIA scores and SSEP recordings (Spearman correlation, P < 0.001). The latter parameters, however, were not related to the outcome of autonomic nerve function (eg detrusor vesicae function) (Spearman correlation, P = 0.1). Therefore, the initial clinical and electrophysiological examinations are of value in assessment of the degree to which the patient will recover somatic nervous control of bladder function. However, these examinations are not indicative of urodynamic impairment. Therefore, urodynamic examination should be mandatory for the diagnostic assessment and therapeutical approach of bladder dysfunction in patients with acute SCI.     

Defecatory disorders in de novo Parkinsonians--colonic transit and electromyogram of the external anal sphincter

Constipation is very common in Parkinson's disease. It is still not known whether constipation is due to a slow transit of the colon or an outlet obstruction. We examined 25 patients (11 women, 14 men, mean age 62 years) with newly diagnosed idiopathic Parkinson's disease. All patients had typical clinical symptoms (with an average score of 11.4 points on the Webster scale); the diagnosis was confirmed by 18F-Dopa-PET. In all patients the colon transit time was measured with radioopaque markers. Pudendal nerve lesions were excluded by neurography of the pudendal nerve. Electromyography of the external anal sphincter was performed with concentric needle electrodes in the right and left lateral position. Colon transit time in the patients averaged 3.7 days, with pathologically prolonged transit (> 4 days) in 6 patients (24%). Four patients (16%) showed mild neurogenic changes on sphincter EMG (16%). In three other cases (12%) long duration and large amplitude of motor unit action potentials (MUAPs), and a reduced interference pattern during maximal voluntary effort indicated a severe neurogenic lesion. One patient presented with involuntary contractions of the external anal sphincter at rest, which increased during strain (anism).     

Usefulness of bladder auto-augmentation in neurogenic bladder: a case report

A 41-year-old male with myelomenigocele underwent a bladder auto-augmentation and endoscopic collagen injections. He has been performing self intermittent catheterization for 10 years but urinary incontinence remained unchanged. Furthermore, he suffered from recurrent pyelonephritis due to the left vesicoureteral reflux. A preoperative fluoroscopic urodynamic study showed a poorly compliant bladder with the maximal bladder capacity of 200 ml at 60 cmH2O. The left vesicoureteral reflux was observed at 10 cmH2O. The low compliant bladder was treated with the bladder autoaugmentation and the left vesicoureteral reflux was treated with the endoscopic subureteral injection of collagen 5 months after the previous operation. A fluoroscopic urodynamic study 6 months postoperatively showed the increase of the maximal bladder capacity of 300 ml at 18 cmH2O and the reflux disappeared completely. The endoscopic periurethral injections of collagen improved his persisting urinary incontinence. In patient with neurogenic bladder having a lot of clinical problems, bladder auto-augmentation is less invasive and offers many advantages over enterocystoplasy.     

Urinary dysfunction in Duchenne muscular dystrophy

In Duchenne muscular dystrophy (DMD), sphincter muscles tend to be clinically spared. However, urinary incontinence is occasionally reported, usually late in the course of the disease. We wished to determine the etiology of urinary dysfunction in patients with DMD. Seven boys with DMD and urinary dysfunction were examined by a neurologist and a urologist followed by urodynamic and electrophysiological assessment. Based on the results of these evaluations, patients were defined as having an upper motor neuron (UMN), lower motor neuron (LMN), or myopathic lesion. Five of the patients had UMN abnormalities consisting of either uninhibited contractions or bladder/sphincter dyssynergy. One patient had a LMN lesion with prolonged duration and high-amplitude motor units. No patient demonstrated myopathic motor units. Five boys had undergone spinal fusion for scoliosis. We conclude that urinary incontinence in DMD is most often due to UMN dysfunction and not due to a severe myopathy of the detrusor or external sphincter. The most likely causes of the UMN abnormalities are severe scoliosis or a complication of spinal fusion surgery.     

Role of pudendal nerve terminal motor latency assessment in constipated patients

The importance of pudendal nerve terminal motor latency assessment for the evaluation of incontinence is well established. However, its role in constipated patients remains unclear. PURPOSE: The purpose of the present study was to assess the incidence of pudendal neuropathy in constipated patients and its correlation with others variables including age, sex, anal pressures, and anal electromyography. RESULTS: From 1988 to 1993, 161 patients with chronic constipation underwent pudendal nerve terminal motor latency assessment, anal electromyography, and anal manometry. The overall incidence of pudendal neuropathy was 23.6 percent; females and males had a similar incidence (24 percent vs. 23 percent, respectively; P > 0.05). Patients over 70 years old had a significantly higher incidence of pudendal neuropathy than did patients under 70 years (37 percent vs. 12 percent, respectively; P < 0.01). Patients with paradoxical puborectalis contraction on anal electromyographic assessment had a higher incidence of bilateral neuropathy, paradoxical puborectalis contraction (+)23 percent vs. paradoxical puborectalis contraction (-)8 percent, P < 0.05. Patients with pudendal neuropathy also had a higher incidence of decreased motor units potential recruitment than did patients without pudendal neuropathy (31.5 percent vs. 17 percent, respectively; P > 0.05). CONCLUSIONS: Pudendal nerve terminal motor latency assessment was able to detect unsuspected pudendal neuropathy in 24 percent of patients. This finding correlated with age and with the presence of paradoxical puborectalis contraction but not with manometric anal pressures, motor unit potentials recruitment, or the presence of polyphasia. However, the often espoused relationship between pudendal latency and external sphincter function could not be demonstrated.     

Neurobiology of postoperative impotence after rectal excision

OBJECTIVE: The present study was conducted to determine the changes in the neuro-andrologic profile of patients with impotence following rectal ablative surgery. METHODS/RESULTS: The study comprised 18 patients who had undergone rectal surgery: abdominoperineal resection of the rectum (AP) in 12 cases (67%), anterior resection of the rectum (AR) in 6 cases (33%). The pharmacologic erection test was negative in 60% of the patients (56% of the AP cases and 67% of the RA cases; differences not significant). Sympathetic lesion was demonstrated in 67% of the patients (50% of the AP cases and 100% of the AR cases; significant difference). Parasympathetic lesion was demonstrated in 38% of the patients (56% of the AP and in none of the RA cases; tendency towards statistical significance). Pudendal lesion was demonstrated in 83% of the patients, although no significant differences concerning pudendal involvement were observed between both types of surgery (92% of the AP group and 67% of the RA group). The frequency of the pudendal lesion was significantly greater than the parasympathetic lesion and the sympathetic lesion tended to be significantly greater than the parasympathetic lesion in patients undergoing ablative rectal surgery. No significant differences were observed between the pudendal and the sympathetic lesion in these patients. No relationship was observed between the type of neurologic lesion and the results of the pharmacologic erection test. CONCLUSIONS: The type of neurological lesion appears to be related with the level of the rectal surgery. The sympathetic innervation would be more frequently compromised in anterior resection of the rectum. The parasympathetic innervation would be more frequently compromised in abdominoperineal resection. The pudendal innervation would be affected by both types of surgical techniques.     

(6-4) photolyase: light-dependent repair of DNA damage

Eight of 32 patients (25%) with chronic inflammatory demyelinating polyneuropathy (CIDP) had micturitional disturbance, which consisted of voiding difficulty (n = 4), urgency (n = 4), or urgency incontinence (n = 1). Urodynamic studies on four symptomatic patients showed disturbed bladder sensation in two, bladder areflexia in one, and neurogenic changes of the external sphincter in one, indicative of peripheral parasympathetic and somatic nerve dysfunctions. Cystometry also showed detrusor overactivity in two patients but no evidence of CNS involvement, evidence that bladder overactivity occurs by probable pelvic nerve irritation.     

The association between dental arch dimensions and occurrence of Finnish dental consonant misarticulations in cleft lip/palate children

The evaluation of cortical evoked potentials after stimulation of the vesicourethral junction shows accurate and reproducible results and offers an elegant technique for evaluation of the viscerosensory pathways in patients with lower urinary tract dysfunction. The results must be considered in context with the results of simultaneously investigated pudendal somatosensory evoked potentials and the clinical symptomatology. They are of great help (1) in differentiating between intraspinal and extraspinal lesions of the afferent pathways of the detrusor if the etiology is unknown, (2) in differentiating between neurogenic and myogenic damage to the urinary bladder, and (3) in selecting patients not suitable for intravesical electrotherapy for bladder rehabilitation.     

Anal and urinary incontinence after obstetric anal sphincter rupture]

The aim of the study was to assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence, and identify factors to predict patients at risk. In 94 consecutive women who had sustained an obstetric anal sphincter rupture, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months post partum was performed. A questionnaire regarding incontinence was sent between two to four years post partum. Forty-two percent of responders had anal incontinence, 32% had urinary and anal incontinence. Overall, 56% of the women had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies > 2.0 milliseconds and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Thirty-eight percent of the women with incontinence wanted treatment, but only a few had sought medical advice.     

Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty

PURPOSE: This study assessed the efficacy of anterior overlapping sphincteroplasty and parameters predictive of a successful outcome. METHODS: Clinical findings and physiologic investigations of female patients who underwent anterior overlapping sphincteroplasty for fecal incontinence between 1988 and 1996 were reviewed. The extent of sphincter damage was assessed at needle electromyography as the number of quadrants exhibiting decreased motor unit potentials. Prolonged pudendal nerve terminal motor latencies were those of greater than 2.2 ms. The size of the endoanal ultrasound defect was assessed as degrees circumference of the external sphincter in which viable muscle was absent. Patients were reviewed by telephone questionnaire and were asked to grade the outcome of their surgery as excellent or good (success) or fair or poor (failure). Incontinence was graded using a scoring system of 0 (perfect continence) to 20 (complete incontinence). RESULTS: There were 100 patients who had an overlapping sphincteroplasty; complete follow-tip information was obtained for 77 patients at a median of 24 (range, 2-96) months. The median age was 47 (range, 25-80) years and they had a median duration of incontinence of four (range, 0.1-39) years. Prior sphincteroplasty had been performed in 30 patients with a median of one (range, 1-7) operations. Investigations performed included electromyography (n = 49), pudendal nerve terminal motor latency (n = 71), endoanal ultrasound (n = 49), and manometry (n = 67). Sixty percent of patients had improved continence and 42 (55 percent) considered their surgery to have been successful as attested to by a significant decrease in their incontinence score (from 15.1 +/- 4.5 to 4.3 +/- 4.2; P < 0.0001). Neither patient age, parity, prior sphincteroplasty, cause or duration of incontinence, extent of electromyography damage, size of the endoanal ultrasound defect, nor any manometric parameter correlated with outcome. However, 62 percent of 59 patients with bilaterally normal pudendal nerve terminal motor latencies had a successful outcome compared with only 16.7 percent of 12 patients with unilateral or bilateral prolonged pudendal nerve terminal motor latencies (P < 0.01). CONCLUSION: Bilateral normal pudendal nerve terminal motor latencies are the only factors predictive of long-term success after overlapping sphincteroplasty.     

Flexible cystoscopy during urodynamic evaluation of spinal cord-injured patients

Eighty-one consecutive flexible cystoscopic examinations were performed on 69 patients with spinal cord injury (SCI) at the time of their urodynamic study. The indications for cystoscopy included hematuria, recurrent urinary tract infections, symptoms of bladder outlet obstruction, the presence of an intraurethral sphincter stent requiring evaluation, neurogenic vesical dysfunction requiring endourodynamic study (cystometrogram through the working port of the flexible cystoscope), or bladder calculi. Flexible cystoscopy was accomplished in all patients, whether lying supine or seated in a wheelchair (N = 16). Only 6 of 39 patients with previous episodes of autonomic dysreflexia became hypertensive during cystoscopy. When a urodynamic catheter could not be inserted, the flexible cystoscope was particularly useful in defining the urethral anatomy or obstruction and in performing endourodynamic evaluation. The only complication was the development of febrile urinary tract infection in four patients. The flexible cystoscope is a valuable tool in the urodynamic laboratory caring for patients with SCI and is effective for use in endourodynamics, especially when patient positioning or catheter placement is difficult. The procedure is well tolerated, causes minimal stimulation leading to the development of autonomic dysreflexia, and provides accurate cystometric data.     

Birth order in homosexual versus heterosexual sex offenders against children, pubescents, and adults

OBJECTIVE: The selection of patients amenable to treatment with a bladder neck sling remains a controversy. In this paper we review our experience with this technique and describe our patient selection criteria. METHODS: Since 1991, 30 patients (24 females and 6 males) aged 4 to 20 years (mean 10) received a bladder neck sling as part of the surgical treatment for their urinary incontinence. The cause of incontinence was neurogenic in 28 of the 30 patients. The 6 male patients were prepuberal. All patients had a preoperative video urodynamic study. The criteria for increasing cervico-urethral resistance included a passive leak point pressure of < 50 cm H2O, stress leak point pressure of < 100 cm H2O, radiological evidence of an open bladder neck and stress incontinence regardless of the other urodynamic and radiologic parameters. The technical aspects of the procedure are described in detail. Augmentation cystoplasty was performed concomitantly in 29 patients. RESULTS: Patient follow-up ranged from 2 to 70 months (mean 37.6). Twenty-eight patients (93%) were continent postoperatively. Two female patients remained incontinent at low leak point pressures. All patients emptied the bladder by intermittent catheterization. Twelve patients perform catheterization through the urethra without difficulty. CONCLUSION: The rectus fascia sling has several advantages over other surgical methods for increasing the cervico-urethral resistance. It is simple, effective, low-cost and has a low complication rate. In our view, the sling is the technique of choice for increasing cervico-urethral resistance in female and prepuberal male patients requiring a cystoplasty concomitantly.     

Selective loss of peripheral blood CD45RO+ T lymphocytes correlates with increased levels of serum cytokines and endothelial cell-derived soluble cell adhesion molecules in patients with chronic idiopathic neutropenia of adults

The cause of urinary or fecal incontinence may be a complex one. A central or peripheral neurogenic lesion is frequently found to be accounting for the problem. The diagnosis should be specified by neurologic examinations and adequate neurophysiologic workup prior to any conservative or surgical treatment. Of particular expressiveness are, neurological history, both neurography of the pudendal nerve and electromyography of the external anal sphincter. Additional measures such as recording of the motor or sensory potentials, determination of reflex latencies and an electromyogram of other striated muscles of the pelvic floor may be taken as needed. Close co-operation of gynecologists, proctologists, and neurophysiologically trained neurologists will help to improve the prospects of treatment and avoid inappropriate therapeutic approaches.     

Epidemiology of toxoplasmosis in Kuwait. I. Detection of antibodies to Toxoplasma gondii and percentage distribution among the inhabitants

Sixty patients presented with postprostatectomy problems. The symptoms of slow stream and hesitancy were associated with the urodynamic finding of an underactive detrusor more often than with persistent obstruction. The symptoms of persistent urgency, frequency, and urge incontinence were associated with bladder hypersensitivity and bladder instability. Stress incontinence was associated with low sphincter pressures demonstrated by urethral profilometry. Urodynamic studies enabled accurate diagnosis of these problems and indicated which patients had persistent obstruction (17 per cent) and would therefore benefit from additional outflow tract surgery.     

The ice-water test in the diagnosis and treatment of the neurogenic bladder

OBJECTIVE: To determine the usefulness of the ice-water test (IWT) in the diagnosis and treatment of neurological bladder disease. PATIENTS AND METHODS: The IWT was carried out in 148 patients with neuropathic bladder dysfunction resulting from a traumatic lesion, to assist in their diagnosis and treatment, and in 130 patients with neuropathic bladder dysfunction and multiple pathogenic disorders; the results of the IWT were used to classify those patients with hyperactive bladders. RESULTS: The IWT was positive in 95% of patients affected by complete and in 86% of patients with incomplete medullary lesions. The IWT in patients with lower motor neuron medullary lesions was always negative. The test was used diagnostically in all patients with lower and in 43% of those with upper motor neuron lesions. In the latter, it was used in 48% of patients as a rehabilitation method during the medullary-shock phase to accelerate the appearance of the micturition reflex. In 9% of patients it was used to induce micturition during cystography. CONCLUSION: Because it is simple to perform, the IWT is a useful complement to urodynamic examinations in patients with neurological bladder disease and in patients with micturitional disorders that are otherwise difficult to interpret.     

Superficial angiomyxoma of the right inguinal region: report of a case

Electromyography (EMG) is the most common procedure for screening patients with myopathies and remains the most important technique for assessing the course of the disease over time. Fibrillation potentials, positive sharp waves, myotonic or complex repetitive discharge, as well as polyphasic potentials are non specific and can occur in both myopathic and neurogenic lesions. The most sensitive and specific parameter for myopathy in conventional EMG is the decreased duration of motor unit potentials (MUP), but this can also be seen in disorders of the terminal motor fibers or the neuromuscular junction. More advanced techniques such as single fiber EMG, macro EMG, scanning EMG and turns/amplitude analysis have opened additional possibilities for analysis of the motor unit and the interference pattern, by which both the sensitivity to early changes and specificity for myopathic alterations is increased. The importance of combining different techniques to improve diagnostic yield and specificity is stressed.     

Sixth congress of the European Genetic Therapy Group

PURPOSE: Course and pathophysiology of a typical syndrome after irradiation of the cauda equina were studied. PATIENTS AND MATERIALS: 7 patients with irradiation damage of the cauda equina were examined clinically and neurophysiologically. RESULTS: After a mean delay of 5 years and 6 months all patients developed an ascending lower motor neuron weakness of the legs without pain, in part accompanied with mild sensory and sphincter symptoms. Electromyography, evoked potentials and neurography were important for the differential diagnosis to tumor infiltration. The course was progredient. DISCUSSION: For a long time, the underlaying damage was thought to be in the anterior horn cell body. The course of the studied patients with additional sensory and vegetative symptoms implies for a direct bilateral damage of the cauda equina. A better term for the syndrome is "post-irradiation cauda-equina-syndrome".     

DNA single strand breakage, DNA adducts, and sister chromatid exchange in lymphocytes and phenanthrene and pyrene metabolites in urine of coke oven workers

During heart transplantation (HTX) all neural connections are severed. In humans, signs of autonomic reinnervation have been found. In this study non-invasive tests were used to compare signs of sympathetic and parasympathetic reinnervation. Non-invasive autonomic function tests and heart rate variability parameters (HRV; 24 h electrocardiographic registration) were used to investigate signs of reinnervation. 16 HTX patients (14 males) were compared with age-and sex-matched controls. Parasympathetic heart rate changes in HTX compared to controls were attenuated during the diving test, deep breathing, the Valsalva maneuver and standing up but not during carotid sinus massage. Sympathetic heart rate increases were lower during the cold pressor test and mental stress. The blood pressure responses were comparable to the control group, but not during active standing and tilting. This finding suggests an obligatory 'blood pressure' role for the innervated heart in these two tests. All HRV parameters were lower in HTX. One or more normal parasympathetic responses were found in 13 out of 16 patients versus 4 out of 16 with normal sympathetic responses (p < 0.05). Heart rate variations were less in case of a higher donor age, and higher in case of a longer time after HTX. Parasympathetic signs of reinnervation are more common than sympathetic signs of reinnervation. A higher donor age reduces signs of reinnervation. If the sympatho-vagal balance is a prognostic factor in HTX patients as it is in other cardiac diseases these findings are clinically relevant.     

Symptoms and immunology of the Henoch-Sch?nlein-syndrome

Established urodynamic and electrophysiological techniques have been applied to assess the frequency and extent of autonomic and peripheral neuropathy in 60 subjects with diabetes mellitus; 38 were diabetics with suggestive symptoms and the others were representative newly diagnosed (11) or treated (11) diabetics. Objective evidence neuropathic bladder dysfunction was detected in 43 of them (71.7%). The commonest abnormality was a hypotonic, insensitive large capacity bladder, which condition was usually asymptomatic. Less freuqently (15%) was this complicated by bladder decompensation and sphincter involvement, resulting in excessive residual urine and infection; some of these had bladder paralysis with chronic painless retention of urine (7%). Electrophysiological studies found a sensory defect in the lower limbs in all tested patients (100%), and in 41 patients (69%) as associated motor conduction abnormality, which was more frequent and marked in the lower than the upper limb. These functional abnormalities appeared to be related to the severity of diabetes, but less to its duration. Indeed of 11 newly diagnosed diabetics tested 7 had a peripheral neuropathy and 4 urodynamic abnormalities. The high incidence of bladder dysfunction and peripheral neuropathy in this series indicates the frequency of subclinical diabetic neuropathy and a factor needing more emphasis in diabetic uropathy.     

Hypertrophic neurons innervating the urinary bladder and colon of the streptozotocin-diabetic rat

Female rats were made diabetic with an intravenous injection of streptozotocin (STZ) producing bladder hypertrophy. Using fluorescent dyes injected into the bladder or the colon, we have measured the size of neurons in various ganglia associated with these organs in control and STZ-diabetic rats. These include (1) postganglionic neurons in the pelvic ganglion, (2) postganglionic neurons in the inferior mesenteric ganglion, (3) dorsal root ganglion neurons, (4) sympathetic chain ganglion neurons, (5) preganglionic neurons in the sacral parasympathetic nucleus, (6) motor neurons in Onuf's nucleus innervating the external urethral sphincter. In addition we have measured neurons in some of these groups for rats which have been maintained on a 5% sucrose in water and restricted food diet. In the STZ-diabetic animals only those neurons which make direct contact with the bladder or the colon were found to be hypertrophied (15-70%). In the diuretic animals, only neurons directly innervating the bladder exhibited hypertrophy. We speculate that a trophic factor transported from the organ to the neuron is responsible for this effect.