[Perineal electrical stimulation and rehabilitation in urinary incontinence and other symptoms of non-neurologic origin]. / Electrostimulation et rééducation périnéale de l'incontinence urinaire et des troubles mictionnels non neurologiques.

A literature survey of 106 articles shows that standard electrostimulation is an effective treatment of urinary incontinence and urinary disorders with bladder instability. Bladder inhibition is obtained by applying an alternating current at a frequency of between 5 and 25Hz and with a pulse width of between 0.2 and 0.5ms. In 19 articles (including three randomized, placebo-controlled studies), good results were achieved in 60 to 90% of cases, depending on the exact method (i.e. chronic or acute stimulation). Standard electrostimulation is also efficient in stress urinary incontinence. Urethral closure is obtained by applying a 50Hz alternating current with, again, a pulse width of between 0.2 and 0.5ms. In 21 articles (including two randomized, placebo-controlled studies), good results were achieved in 47.5 to 77% of cases. Treatments combining perineal rehabilitation (behavioural education, muscle improvement and biofeed-back) and electrostimulation are reported by 10 authors, with good results in 70 to 80% of cases after 10 to 12 sessions. According to 14 studies, neuromodulation is also an efficient treatment for complex urinary disorders, urgency, pollakiuria and dysuria. The recommended stimulation parameters are a frequency of 10 to 15Hz and a pulse width of 210ms. Good results were found in 34 to 94% of cases (with between 60 and 75% in an international, multicenter study). The overall results different from one study to another because of the need to harmonize stimulation parameters, choice of the study population and treatment follow-up with self-training programs and therapeutic education.

[Neuropathy with non-alcoholic thiamine deficiency: two cases of bladder disorders]. / Neuropathies par carence en thiamine sans intoxication alcoolique: deux cas de troubles vésicosphinctériens.

INTRODUCTION: Neuropathy with non-alcoholic thiamine deficiency is reported in the literature, but bladder disorders are rarely detailed. CASE REPORTS: We report two cases of bladder disorders in neuropathy with thiamine deficiency. One patient presented with a flaccid bladder and impaired sensation; the postvoid residual volume was raised. The other patient had reduced bladder capacity, with detrusor hyperreflexia and detrusor-sphincter dyssynergia. In both cases, the bladder disorders disappeared with thiamine supplementation. CONCLUSION: Bladder symptoms may be heterogeneous in nonalcoholic neuropathy. The prognosis is good after vitamin supplementation.

Intraspinal lipomas with spina bifida. Prognosis and treatment in 73 cases.

The authors present a series of 73 cases of intraspinal lipomas in the lumbosacral region. Sixty-four patients were operated on, 43 of these under intraoperative monitoring of neural function. The results of this series and of major series published in the past 10 years demonstrate both the potential severity of these lesions (which are responsible for progressive neurological deficits in 56% of affected cases) and the benignity of their surgical treatment. The authors emphasize the usefulness of systematic early surgical treatment of these lesions.

[Prevalence of anal incontinence in adults]. / Etude de la prévalence de l'incontinence anale chez l'adulte.

Inquiries were conducted to determine the prevalence of anal incontinence in a) the general population over 45 by a gallup poll studying 1,100 persons (A); b) 3,914 patients seen by their general practitioner or their gastroenterologist during the same week (B); c) 500 patients consulting for urinary stress incontinence (C1); d) 1,136 neurological patients suffering from micturation disorders (C2); and e) 10,157 elderly persons living in retirement homes or in hospital (D). In the general community (A), the prevalence of anal incontinence, including gas and stool incontinence, was 11 percent, the prevalence of fecal incontinence, 6 percent, the prevalence of daily or weekly fecal incontinence, 2 percent; prevalences were respectively 15.5 percent, 7.9 percent, and 3.2 percent in group B, and 27 percent, 9 percent and 3.8 percent in group C1. The prevalence of fecal incontinence was 18 percent in group C2 and 33 percent in group D. Prevalence did not depend on age in group A and C1, but was twofold higher in group C1 than in group A. The prevalence increased with age in groups B and D.

[Spontaneous muscular haematomas in hemiplegic patients receiving anticoagulation therapy]. / Hématomes musculaires spontanés chez les patients hémiplégiques sous traitement anticoagulant.

INTRODUCTION: Muscular hematomas are frequently reported as a complication of anticoagulation therapy. METHODS: We report six cases of spontaneous muscular hematomas occurring in hemiplegic patients receiving anticoagulation therapy using heparin, low-molecular-weight heparin or fluindione. Anticoagulation therapy was given in prophylactic doses to two patients to prevent deep vein thrombosis and in therapeutic doses to four patients with deep vein thrombosis, pulmonary embolism or cardiac arrhythmia. Two patients experienced episodes of bleeding when heparin and fluindione were temporarily associated. RESULT: Contrary to previous reports, the more frequent site of bleeding was not the ilio-psoas muscle (only 2 patients); hematomas were also observed in hip adductors and gluteus muscles. The most striking finding was the constant location of the hematoma on the hemiplegic side. CONCLUSION: Location on the hemiplegic side can lead to underestimating the frequency of neurologic compression by the hematoma; the diagnosis can nevertheless be established by electromyography. Local signs may not be present, but general signs of hypovolemia and anemia are more frequent. Ultrasound may be the first line investigation but in our experience, the results can be misleading and computed tomography (CT) or MRI are often required to confirm the diagnosis.

[Alcock's canal syndrome and perineal neuralgia]. / Syndrome du canal d'Alcock et névralgie périnéale.

Fifteen cases of perineal neuralgia are reviewed, the lesion arising from a canal syndrome due to compression of the pudendal nerve in the ischiorectal fossa (Alcock's canal syndrome). The clinical characteristic of the pain syndrome was its postural nature with the existence of a true Tinel sign (increased pain on sitting). Diagnosis was confirmed in all cases by a perineal electrophysiological which showed peripheral neurogenic signs on examination of perineal muscles and an increase in sacral evoked potentials latencies (latency of bulbocavernous or clitorido-anal reflexes, cortical somesthetic evoked potential from pudendal nerve). Treatment was infiltration of cortisone derivatives into the pudendal nerve canal, under CT guidance because of the difficulty of infiltrating the pudendal nerve by an external perineal approach. Results were satisfactory in 9 of the 15 patients.

[Bladder sphincter disorders in Parkinson's disease]. / Les troubles vésico-sphinctériens de la maladie de Parkinson.

Clinical and urodynamic examinations were carried out in 63 patients with Parkinson's disease presenting with disorders of the urinary bladder sphincters with no detectable other neurological or urological cause. The incidence of these disorders varies greatly according to different authors this being likely due to a lack of their recognition in routine examinations. In many cases of the present series they were the initial symptom of the disease. The most frequent complaint was urgency of micturition, alone or associated with dysuria, the latter alone being much rarer. Urinary incontinence as a result of one or the other of these disturbances was a frequent feature. Overall clinical characteristics confirm the central neurologic origin of these disorders. Cystometry demonstrated detrusor hyperactivity in 60 p. cent of cases and hypoactivity in 35 p. cent. An electromyogram of the striated sphincter muscle and/or a urethral pressure graph were recorded in some patients. On the whole urodynamic data indicated detrusor muscle dysfunction as being the cause of the micturition disorders. L-Dopa could modify these disorders by increasing detrusor hypoactivity, probably through a central action. Anticholinergic agents provided good therapeutic results when detrusor hypoactivity was involved but it was much more difficult to improve hypoactivity. Data suggesting the role of basal ganglia lesions in detrusor dysfunction in Parkinson's disease are discussed.

[The neurophysiology of micturition (author's transl)]. / Neurophysiologie de la miction.

The ortho and parasympathetic nervous system as well as the somatic nervous system make up the innervation of the lower urinary tract. This constitutes the autonomic nervous system of these organs. There are control centres in the cortex, the sub-cortex and the medullary areas of the brain as well as this peripheral innervation. Together they make possible by their various connections a variety of regulatory circuits and a series of reflexes for micturition which bring about a complex assembly coming from the cortex to the sphincter mechanism of the bladder.

[Pyomyositis in an immunocompetent adult: unusual complication of rhabdomyolysis]. / Pyomyosite chez une patiente non immunodéprimée: complication inhabituelle d'une rhabdomyolyse.

INTRODUCTION: Non-tropical pyomyositis is a commonly reported infection in immunodeficient patients' muscle but is rare without immunodeficiency. CASE DESCRIPTION: We report the case of a 40-year-old woman admitted in the physical medicine and rehabilitation department for a motor and sensory loss of the lower limb; this disorder appeared after rhabdomyolysis due to prolonged lying position (suicide attempt). The initial diagnosis of sciatic nerve compression was not consistent with motor loss of adductor muscles. Clinical examination revealed soft tissue swelling in the proximal part of her lower limb. CT scan displayed pyomyositis of the thigh (hip adductors and gluteus medius), which was successfully treated by surgical incision and drainage in combination with antibiotherapy. CONCLUSION: Non-tropical pyomyositis is rarely described without immunodeficiency but this diagnosis should be borne in mind when previous muscle trauma is associated to leukocytosis. Computed tomography and MRI are the tests of choice to confirm the diagnosis of pyomyositis and to differentiate it from other entities.

[Suprapubic reflex. Electrophysiological study in normal patients]. / Le réflexe pubo-caverneux. Démonstration électrophysiologique.

INTRODUCTION: In spinal cord injuries patients, tapping the suprapubic aera is a strong stimulus to ellicit detrusor contraction and can be used in the management of neurogenic bladder. This stimulation also determines a perineal muscles contraction. This striated response was mentionned in animal studies but never specifically analysed in men especially in normal subjects. AIMS OF THE STUDY: Our objective was to describe pelvic floor responses with measurement of reflex latency following suprapubic mechanical stimulation. METHODS: 21 patients without neurological disease were studied. They were 14 women and 7 men. Mean age was 51 (SD=14,2). Motor responses were recorded with a needle electrode inserted in the left bulbocavernosus muscle. Stimulation was delivered with an electromechanical hammer, tapping directly on the suprapubic aera. RESULTS: A polyphasic muscular response was always and easily elicited in all patients. Mean latency was 67,5 ms. (SD = 14,7). The reproducibility between the first and second mechanical responses was good with no statistical difference (r=0,966; p=0,0001). DISCUSSION: Our study clearly demonstrates a suprapubic bulbocavernosus reflex (SBR). Many arguments can be retained for a polysynaptic reflex (polyphasic response, habituation and short latency of the reflex, mean latency in the habitual values of R2 responses following electrical stimulation of the dorsal nerve of the penis). We hypothetize that: the true stimulus is the stimulation of the bladder wall tenso-receptors; integration level of the SBR is the sacral segments and the efferent limb the pudendal nerve; afferent pathways could be vehicled by pelvic nerve fibers. CONCLUSION: Competition between a preponderant (or exaggerated) SBR and a bladder contraction following suprapubic tapping, may constitute a real functional outlet obstruction giving incomplete or complete retention in some suprasacral bladders. In normal subjects, SBR can be considered as a continence reflex with increase of perineal tone following the stimulation of the bladder wall tenso-receptors during stress.

[The shoulder-hand syndrome after stroke: clinical factors of severity and value of prognostic score of Perrigot]. / Algoneurodystrophie du membre supérieur de l'hémiplégique : facteurs cliniques de gravité et intérêt du score pronostique de Perrigot.

PURPOSE: The purposes of this study were to evaluate the prognostical factors of reflex sympathetic dystrophy in stroke patients in attempt to improve the Perrigot prognostical score. MATERIAL AND METHOD: This prospective study included 28 stroke patients with reflex sympathetic dystrophy. An initial clinical assessment including Perrigot score was made at the time of admission (before the end of the first month) and a second evaluation of reflex sympathetic dystrophy at the end of the third month. Patients were assessed using Motricity Index, Ashworth scale, de Bats grading (for glenohumeral alignment), Labrousse criteria (for reflex sympathetic dystrophy severity), and MADRS depression scale. Sensory deficit and unilateral neglect were noted. RESULTS: The length of stay in acute ward was 16 days. The Perrigot score was correlated with the reflex sympathetic dystrophy severity (r = 0.7, p < 0.0001). It predicted the result of therapy. A significant correlation was found between reflex sympathetic dystrophy severity and motor deficit (r = -0.591, p = 0.0007) and spasticity (p < 0.05). No relation was found with stroke side, unilateral neglect, depression or shoulder subluxation. It wasn't possible to improve the Perrigot prognostical score. CONCLUSION: Perrigot score predict reflex sympathetic dystrophy severity and the result of therapy. The shoulder subluxation which is not included in this score appears to be not predictive. Shoulder subluxation is simply a marker of a severe paresis.

[Neurogenic bladder, 20 years later]. / Vessie neurologique, 20 ans après.

The therapeutic armamentarium--physical therapy, drugs, surgery--developed over the last 20 years now gives us the means of providing curative care to nearly all patients with manifestations of neuropathic bladder, meaning that the clinical examination and complementary tests must be conducted under strictly controlled conditions to identify the underlying mechanism. The examination of the perineum almost always reveals a defect when the origin is neurological but is often normal when gynaecologic or urologic factors are involved. Motor command, tonus, reflexes and sensitivity should all be carefully explored to distinguish between central and peripheral causes. Much progress has been made in complementary examinations. For example, nearly 100% of the neurological aetiologies can be identified with precision. Tests include electromyography of the perineum, measurement of the latency of the bulbocavernous reflex and that of the distal part of the internal pudental nerve. Complementary tests evaluating bladder and sphincter function include urine sediment with cytology, intravenous pyelography and echography of the urinary tract. Pressure measurements with cystomanometry, sphincterometry and flowmetry add further precisions. Whether the underlying mechanism of bladder dysfunction is purely neurological as is the case in many young patients with multiple sclerosis, spina bifida or caudia equina syndrome, results from several causes as in patients with Parkinson's disease and enlargement of the prostate, or is among the increasing number of post-radiation sequellae, the essential step is careful clinical examination and detailed interpretation of complementary examinations. Thus the wide range of techniques now available for the management of the neuropathic bladder can be adapted to each individual case according to the pathological processes causing the clinical manifestations.

[Value of the stop-test in the diagnosis of detrusor hyperactivity. Concept of the isometric zone. Preliminary study of 30 cases]. / Intérêt du stop-test dans le diagnostic des hyperactivités détrusoriennes. Notion d'aire isométrique. Etude préliminaire de trente cas.

The authors propose a new pathophysiological and diagnostic approach to detrusor hyperactivity by the study of the isometric pressure obtained during the stop-test. This test consists of the sudden interruption of micturition by voluntary contraction of the striated urethral sphincter, resulting in sudden contraction of the bladder against the closed sphincter. This isometric contraction is equal to 20 to 30 cm of water. The increase in the pressure (delta P) between the basal micturition pressure and the absolute value of the isometric pressure (P iso) reflects the contractile force of the detrusor. The progressive return to the basal micturition pressure reflects the relaxation of the detrusor, which is the sum of visco-elastic properties and the mechanisms of cortico-sub-cortical neurological inhibition. Calculation of the isometric area (delta P X T/2), where T represents the time taken to return to the initial pressure, allows cases of central neurological hyperactivity (isometric area always greater than 100) to be distinguished from cases of detrusor hyperactivity of mechanical origin (isometric area less than 80). These data have been confirmed in a series of 30 patients.

[Perineal neuralgia and Alcock's canal syndrome]. / Névralgies périnéales et syndrome du canal d'Alcock.

Perineal neuralgia is characterised clinically by pain (burning type of perineal pain) exacerbated in the sitting position. It is secondary to impairment of the internal pudendal nerve in its musculo-osteo-aponeurotic tunnel composed by the ischium and the obturator internus muscle (ischiorectal fossa or pudendal canal). As in any nerve tunnel syndrome, pre-existing neuropathy constitutes a predisposing factor and should therefore be identified. The diagnosis of pudendal tunnel syndrome is confirmed by perineal electrophysiological investigations (detection of neurogenic muscles of the perineal floor, increased sacral latency). Treatment consists of infiltration, possible repeated, of the pudendal tunnel with a sustained-release corticosteroid under CT guidance.

[The uretheral syndrome in men or prostatodynia]. / Syndrome uréthral de l'homme ou prostatodynie.

Based on the results of the clinical and urodynamic investigation of 15 patients, presenting with functional genitourinary symptoms, the authors report the efficacy of treatment with alpha-blockers. They stress the importance of the clinical history and of static sphincterometry in this type of patient.

[Restoration of urinary tract continuity in a non-functioning bladder after renal transplantation]. / Rétablissement de la continuité urinaire après transplantation rénale dans les vessies exclues.

The restoration of the continuity of the urinary tract after renal transplantation in anuric patients, an increasingly frequent situation, raises a number of theoretical problems: is it possible to use a bladder which has been non-functioning, sometimes for many years (20 years)? What should be performed during pre-operative assessment? Which surgical technique should be used? The authors try to answer these questions on the basis of their experience of 116 transplanted anuric patients. Anuria, even of long duration, does not prevent the use of the bladder, provided that the bladder was originally normal and is not infected. The pre-operative assessment is the same as for other patients and urodynamic investigations are not required. The optimal reimplantation technique is the Leadbetter-Politano open bladder technique and every effort should be made to obtain abundant diuresis immediately. Under these conditions, reimplantation into these non-functioning bladders is not associated with more complications than in the case of normal bladders.

[Abnormalities of the sensation of the need to urinate in multiple sclerosis. Clinical and urodynamic study. Apropos of 100 cases]. / Les anomalies de la sensation du besoin d'uriner au cours de la sclérose en plaques. Etude clinique et urodynamique. A propos de cent cas.

A hundred patients with multiple sclerosis and urinary disorders were examined clinically and by gas or water cystometry. Particular attention was paid to abnormalities in the voiding need sensation. These abnormalities can best be studied by cystometry combined with urethral striated sphincter electromyography. When the sequence of the three degrees of need (usual need, pressing need and urgent need) is respected, there is a good correlation between the progression of the voiding need during the filling phase of the cystometry and during the detrusor action. When there is interference with the sequence of these three degrees of the voiding need, especially the absence of the sensation normally contemporaneous with the detrusor action or immediately preceding it, there is exaggeration of either the hyperactivity or the hypoactivity of the bladder, and this aggravates vesical sensitivity: premature contraction of the detrusor muscle eliminates the first two degrees (usual need and pressing need), while progressive distension of the detrusor muscle eliminates all three stages. As the multiple sclerosis evolves a stage is reached at which there are functional mictional disorders exclusively connected with the interference with the degrees of voiding need pollakiuria and urgency.