How long does the effect of botulinum toxin in neurogenic patients last? An analysis of the subset of "good responders".

BACKGROUND: The aim of this study was to assess long-term efficacity of botulinum neurotoxin A (BoNT-A) in the treatment of neurogenic detrusor overactivity (NDO). MATERIALS AND METHODS: This was a retrospective monocentric study in a reference center. We included patients who received intradetrusor BoNT-A for NDO between 2001 and 2015. The focus of our analysis was on patients defined as "good responders" (≥ 5 injections of intradetrusor BoNT-A over a period of ≥5 years). The primary endpoint was the evaluation of long-term efficacity of BoNT-A. Recurrent NDO was monitored by the use of cystomanometry before the first injection and 1 month after each injection. The secondary objective was to assess the influence of NDO's etiology, age, and sex on the long-term efficacity of the treatment. RESULTS: A total of 107 patients were included (60.7% with spinal cord injury [SCI] and 36.4% with multiple sclerosis [MS]). The mean follow-up period was 83.7 months (66; 120). The mean number of injections was of 8.9 (5; 21). A total of 67.3% (n = 72) of patients were still controlled by treatment at the end of their follow-up period. Therapeutic failure occurred in 30 patients (26.1%) with a cessation of BoNT-A treatment at 76 months on average (median: 82.5 months). There was no significant impact of age (P = .42), sex (P = .35), or NDO's etiology (MS vs SCI; P = .54) on long-term efficacy of BoNT-A treatment. CONCLUSION: The results of our study indicate that the application of BoNT-A seems to be an effective and durable treatment in a large number of neurogenic patients after more than 10 years of follow-up. However, botulinum toxin tolerance occurred in approximately 25% of patients.

Genital Sensory Detection Thresholds and Patient Satisfaction With Vaginoplasty in Male-to-Female Transgender Women.

INTRODUCTION: Gender-affirming surgery is common for the treatment of gender dysphoria, but its effect on genital sensitivity is not well known. AIMS: To investigate genital sensory detection thresholds in male-to-female transgender women postoperatively and their relation to psychological well-being and variables of satisfaction. METHODS: Prospective study on 28 transgender women at least 18 years old operated on at least 3 months before the study by a single surgeon (N.M.J.). MAIN OUTCOME MEASURES: Medical complications; sensory detection thresholds for light touch, pressure, and vibration; and questionnaires on general and sexual satisfaction, sexual function, depression, and psychological well-being. RESULTS: Sensory detection thresholds ranged from 0.07 to 2.82 g for light touch, with the neck being most sensitive; from 20.23 to 34.64 g for pressure, with similar results for the neck and clitoris; and from 0.0052 to 0.0111 V for vibration, with similar findings for all stimulation points. Satisfaction with the appearance of the labia, vulva, clitoris, and sexual function was good to very good. Frequency of sexual activities increased significantly postoperatively for orogenital stimulation and decreased significantly for frequency of fantasies (t = -4.81; P < .0001). Orgasmic function was reported by 80% of participants. Psychological adjustment was good to very good, with low depression scores. Sexual satisfaction was statistically and positively correlated with vaginal function and depth, clitoral sensation, appearance of the vulva and labia minora, and natural lubrication and negatively correlated with depression scores. CONCLUSION: Gender-affirming surgery yields good results for satisfaction with appearance and function. Genital sensitivity showed the best results with pressure and vibration.

The control of male sexual responses.

Male sexual responses are reflexes mediated by the spinal cord and modulated by neural circuitries involving both the peripheral and central nervous system. While the brain interact with the reflexes to allow perception of sexual sensations and to exert excitatory or inhibitory influences, penile reflexes can occur despite complete transections of the spinal cord, as demonstrated by the reviewed animal studies on spinalization and human studies on spinal cord injury. Neurophysiological and neuropharmacological substrates of the male sexual responses will be discussed in this review, starting with the spinal mediation of erection and its underlying mechanism with nitric oxide (NO), followed by the description of the ejaculation process, its neural mediation and its coordination by the spinal generator of ejaculation (SGE), followed by the occurrence of climax as a multisegmental sympathetic reflex discharge. Brain modulation of these reflexes will be discussed through neurophysiological evidence involving structures such as the medial preoptic area of hypothalamus (MPOA), the paraventricular nucleus (PVN), the periaqueductal gray (PAG), and the nucleus para-gigantocellularis (nPGI), and through neuropharmacological evidence involving neurotransmitters such as serotonin (5-HT), dopamine and oxytocin. The pharmacological developments based on these mechanisms to treat male sexual dysfunctions will complete this review, including phosphodiesterase (PDE-5) inhibitors and intracavernous injections (ICI) for the treatment of erectile dysfunctions (ED), selective serotonin reuptake inhibitor (SSRI) for the treatment of premature ejaculation, and cholinesterase inhibitors as well as alpha adrenergic drugs for the treatment of anejaculation and retrograde ejaculation. Evidence from spinal cord injured studies will be highlighted upon each step.

Side effects of intradetrusor botulinum toxin injections on ejaculation and fertility in men with spinal cord injury: preliminary findings.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The beneficial effect of intradetrusor botulinum toxin (BT) injections on hyperactive bladders in individuals with spinal cord injury is known from the literature, but its potential effect on ejaculation and fertility through diffusion is not. As BT injection paralyses the bladder muscle, it may also paralyse the muscular envelopes of the adjacent reproductive organs and lead to potential negative side effects, which have not been studied yet. This study provides preliminary data on the potential negative side effects of BT injections on semen volume and retrograde ejaculation, as well as some potential beneficial effects on semen quality. OBJECTIVE: To investigate the effect of botulinum neurotoxin A on ejaculation potential and fertility. Intradetrusor injection of botulinum neurotoxin A is most commonly used nowadays to treat overactive bladder in patients with spinal cord injury (SCI). PATIENTS AND METHODS: Retrospective analyses were carried out of 11 patients with complete lesions from C5 to T6 who had received botulinum (BT) injections for their overactive bladder and who had undergone ejaculation tests before and after BT treatment. RESULTS: BT treatment was found effective in improving bladder function in up to 85% of the cases. While no patients maintained natural ejaculation following their SCI, BT treatment was found to increase the incidence of retrograde ejaculation (vibrostimulation) in 46% of cases and to diminish semen volume in 77% of cases, from an average of 1.8 mL to 1 mL. Semen quality was slightly improved following BT treatment, sperm mobility increased in 67% of cases, sperm vitality in 50% and semen culture improved in 43%. CONCLUSIONS: BT treatment has beneficial and detrimental effects on ejaculation function. The detrimental effects involve retrograde ejaculation and reduced semen volume, which are explained by the spread of toxin to the bladder neck, reducing its tonus, and to the smooth muscle sexual accessory organs, reducing the strength of their contraction. The beneficial effects are explained by the reduced contamination of the semen by urinary infection, which may improve spermatogenesis and subsequent semen quality. The results are discussed in terms of their clinical implications and advice to patients.

Assessing and conceptualizing orgasm after a spinal cord injury.

OBJECTIVES: To provide a questionnaire for assessing the sensations characterizing orgasm. To test the hypothesis that orgasm is related to autonomic hyperreflexia (AHR) in individuals with a spinal cord injury (SCI). SUBJECTS AND METHODS: A total of 97 men with SCI, of whom 50 showed AHR at ejaculation and 39 showed no AHR, were compared. Ejaculation was obtained through natural stimulation, vibrostimulation or vibrostimulation combined with midodrine (5-25 mg). Cardiovascular measures were recorded before, at, and after each test. Responses to the questionnaire were divided into four categories: cardiovascular, muscular, autonomic and dysreflexic sensations. RESULTS: Significantly more sensations were described at ejaculation than with sexual stimulation alone. Men with SCI who experienced AHR at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who did not. There was no difference between men with complete and those with incomplete lesions. CONCLUSIONS: The findings show that the questionnaire is a useful tool to assess orgasm and to guide patients in identifying the bodily sensations that accompany or build up to orgasm. The findings also support the hypothesis that orgasm may be related to the presence of AHR in individuals with SCI. Data from able-bodied men also suggest that AHR could be related to orgasm, as increases in blood pressure are observed at ejaculation along with cardiovascular, autonomic and muscular sensations.