[Pelvic floor muscles training, electrical stimulation, bladder training and lifestyle interventions to manage lower urinary tract dysfunction in multiple sclerosis: a systematic review]. / Troubles du bas appareil urinaire chez des patients atteints de la sclérose en plaques et kinésithérapie pelvi-périnéale : revue systématique.

AIM: To assess the effectiveness of conservative therapeutic approaches in a multiple sclerosis population. MATERIAL: Review was performed in PubMed, PEDro, Scopus and Cochrane Library using combinations of the following keywords: multiple sclerosis; bladder dysfunction; overactive bladder; detrusor hyperreflexia; urge incontinence; urgency; stress incontinence; pelvic floor muscle; biofeedback; PTNS; tibial nerve; bladder training; physical therapy; physiotherapy; conservative treatment and behavioral therapy. RESULTS: Six randomized articles including 289 patients were selected. Four papers exhibited strong scores for the methodological quality assessment. The parameters always significantly improved concerned: number of incontinence episodes (decreased from 64% to 86% after treatment versus before treatment), quality of life (P≤0.001), severity of irritative symptoms (decreased by more than 50% after treatment versus before treatment), and nocturia (P=0.035 to P<0.001). Activities and participation, maximum flow rate, mean voided volume and daytime frequency were not significantly improved in all trials. CONCLUSIONS: The physical therapy techniques could be effective for the treatment of urinary disorders in multiple sclerosis populations with mild disability. However, the analyses are based on six studies within only four showed good methodological quality. No strong conclusions regarding treatment approaches can be drawn from this review.

[Physiotherapy and neurogenic lower urinary tract dysfunction in multiple sclerosis patients: a randomized controlled trial]. / Kinésithérapie et symptômes du bas appareil urinaire chez des patients atteints de la sclérose en plaques : étude contrôlée randomisée.

AIM: This randomized controlled trial compare the efficacy of pelvic floor muscle training vs. transcutaneous posterior tibial nerve stimulation. PATIENTS AND METHODS: Inclusion criteria were EDSS score<7 and presence of lower urinary tract symptoms. Exclusion criteria were multiple sclerosis relapse during the study, active urinary tract infection and pregnancy. The primary outcome was quality of life (SF-Qualiveen questionnaire). Secondary outcomes included overactive bladder (USP questionnaire) score and frequency of urgency episodes (3-day bladder diary). Sample size was calculated after 18 patients were included. Data analysis was blinded. Each patient received 9 sessions of 30 minutes weekly. Patients were randomized in pelvic floor muscles exercises with biofeedback group (muscle endurance and relaxation) or transcutaneous posterior tibial nerve stimulation group (rectangular alternative biphasic current with low frequency). RESULTS: A total of 31 patients were included. No difference appeared between groups for quality of life, overactive bladder and frequency of urgency episodes (respectively P=0.197, P=0.532 et P=0.788). These parameters were significantly improved in pelvic floor muscle training group (n=16) (respectively P=0.004, P=0.002 et P=0.006) and in transcutaneous posterior tibial nerve stimulation group (n=15) (respectively P=0.001, P=0.001 et P=0.031). CONCLUSIONS: Pelvic floor muscle training and transcutaneous posterior tibial nerve stimulation improved in the same way symptoms related to urgency in MS patients with mild disability. LEVEL OF EVIDENCE: 2.

What is the place of electroneuromyographic studies in the diagnosis and management of pudendal neuralgia related to entrapment syndrome?

Entrapment of the pudendal nerve may be at the origin of chronic perineal pain. This syndrome must be diagnosed because this can result in the indication of surgical decompression of the entrapped nerve for pain relief. Electroneuromyographic (ENMG) investigation is often performed in this context, based on needle electromyography and the study of sacral reflex and pudendal nerve motor latencies. The limits of ENMG investigation, owing to various pathophysiological and technical considerations, should be known. The employed techniques do not assess directly the pathophysiological mechanisms of pain but rather correlate to structural alterations of the pudendal nerve (demyelination or axonal loss). In addition, only direct or reflex motor innervation is investigated, whereas sensory nerve conduction studies should be more sensitive to detect nerve compression. Finally, ENMG cannot differentiate entrapment from other causes of pudendal nerve lesion (stretch induced by surgical procedures, obstetrical damage, chronic constipation...). Thus, perineal ENMG has a limited sensitivity and specificity in the diagnosis of pudendal nerve entrapment syndrome and does not give direct information about pain mechanisms. Pudendal neuralgia related to nerve entrapment is mainly suspected on specific clinical features and perineal ENMG examination provides additional, but no definitive clues, for the diagnosis or the localization of the site of compression. In fact, the main value of ENMG is to assess objectively pudendal motor innervation when a surgical decompression is considered. Perineal ENMG might predict the outcome of surgery but is of no value for intraoperative monitoring.

Visual sexual stimulation plethysmography: complementary test to nocturnal penile plethysmography.

Diurnal penile plethysmography under visual sexual stimulation (VSS) and nocturnal penile tumescence (NPT) plethysmography have been performed in 5 healthy volunteers and 195 consecutive men complaining of impotence. Our study demonstrates that VSS plethysmography may compensate at least partially for the shortcomings of classic NPT plethysmography, by allowing direct clinical estimation of "erectile performance." Twenty percent of the patients had full erection under VSS. These patients do not need further testing. VSS is a noninvasive and useful "first-line" investigation in erectile dysfunction.

Undetectable prostate-specific antigen in aging men.

Undetectable prostate-specific antigen was found in three aging men despite the absence of any prostatic surgery or exogenous hormonal deprivation. Clinical and elementary hormonal workup revealed the presence of secondary hypogonadism. This finding confirms the hormonal dependency of this prostatic marker and may, in some cases, explain the discrepancy between prostatic volume and the value of serum prostate-specific antigen.

Neuromagnetic somatosensory homunculus: a non-invasive approach in humans.

The somatosensory homunculus has been identified during stimulation of median (at wrist and elbow), femoral, tibial and pudendal nerves of the left hemibody via the neuromagnetic imaging technique. The somatic representations of different body districts have been localized in the somatosensory cortex, by means of an equivalent dipole localization algorhythm. Dipole locations agree with the well-known somatotopic organization obtained with invasive techniques. The proposed method is, therefore, an important investigating tool for studies on normal and diseased subjects.

Transurethral ultrasound-guided laser-induced prostatectomy: a critical evaluation.

We evaluated 38 patients with a follow-up of 30 months after transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia. The mean symptom score decreased by 54%, and peak urinary flow increased by 112%. For the entire series, 43.6% of the patients had an improved symptom score and 41% better urinary flow, but only 28.2% had improvement in both. Six patients (16%) required reoperation, two underwent a radical prostatectomy, and one patient presented total urinary incontinence. Also, 19% presented postoperative impotence, and 47% presented retrograde ejaculation. Although one third of the patients are improved with the TULIP procedure, the rate of complications is significantly higher than for TURP, which remains the most effective treatment of obstructive BPH.

[Contribution of the preoperative urodynamic findings in the determination of risks factors of urinary incontinence after radical retropubic prostatectomy]. / Apport de l'exploration urodynamique préopératoire dans la détermination des facteurs de risques de l'incontinence post-prostatectomie radicale totale.

UNLABELLED: The aim of the study was to determine whether preoperative urodynamic evaluation helps the physiotherapist to adapt preoperative management of patients undergoing radical retropubic prostatectomy (RP) by identifying a group at risk of incontinence. MATERIAL AND METHODS: We compared the preoperative urodynamic evaluation of 229 men scheduled for RP with their continence status, evaluated by standardized pad-test and questionnaire, at 6 weeks and 4 months postoperatively. RESULTS: The primary urinary incontinence risk has been obtained for five patient's categories, namely normal, bladder instability, bladder outlet obstruction, hypocontractility, and mixed results. None of the patients diagnosed with detrusor instability and bladder outlet obstruction was continent at six weeks from surgery. At four months, although it improves, the continence status remains significantly poorer than observed in all other groups. CONCLUSION: Preoperative urodynamic evaluation of patients scheduled for RP allows identifying patients with a high risk of postoperative urinary incontinence.

[Uroradiology]. / Uroradiologie.

Radiology of the urinary tract has a great place in evaluating voiding dysfunction. The role of the radiologist is not limited to diagnosis of the sequelae of voiding dysfunction but he must provide information about causes, mechanisms and helps to provide a more accurate diagnosis. Projectional radiography (excretory urography, voiding cysto-urethrography) is still the best method of evaluation in spite of development of new imaging techniques (ultrasonography, computerized axial tomography, magnetic resonance imaging). Radiodynamic examination of the lower urinary tract is the best method of choice to study the complex functional problems involving those structures.

[Motor evoked potentials of the perineal floor. Preliminary results]. / Les potentiels évoqués moteurs du plancher périnéal. Résultats préliminaires.

Neuromotor pathways from the brain to the pelvic floor have been poorly documented. The recent development of Motor Evoked Potentials may well fill this gap in our basic knowledge. Our technique consists of transcutaneous stimulation of the motor cortex and sacral roots with a magnetic device while recording the evoked response from the bulbocavernosus muscle and anal sphincter. Cortical stimulation is performed first at rest and then during voluntary contraction of the examined muscles ("facilitation" procedure). Sacral root stimulation is performed at rest. Stimulation at 2 different levels allows measurement of the total transit time (brain to muscle transit time) and the peripheral transit time (sacral roots to muscle). By subtracting the latter from the former, the central transit time (brain to sacral roots) is obtained. The technique is painless, and to our knowledge no side effects have been reported. The authors present the preliminary results of this new technique.

[Ureteral lithiasis. Development of the therapeutic strategy and the place of endoscopic treatment]. / Lithiases urétérales. Evolution de la stratégie thérapeutique et place du traitement endoscopique.

In order to evaluate the impact of endourological techniques and extracorporeal lithotripsy on the management of ureteral calculi, we reviewed the charts of 838 patients requiring hospitalization for this pathology from 1982 till 1987. 314 patients were managed conservatively and 524 required intervention therapy: 52 with blind endoscopic techniques, 93 with open surgery, 122 with retrograde ureteroscopy, 168 with percutaneous extraction and 92 with ESWL. Evolution of the therapeutic strategy is discussed and our present approach to ureteral stone management is outlined.

[Urinary continence after radical prostatectomy: importance of the vesico-urethral anastomosis. Objective evaluation]. / Continence urinaire après prostatectomie radicale: importance de l'anastomose vésico-urétrale. Evaluation objective.

Urinary continence after radical prostatectomy is frequently evaluated subjectively. The authors describe their technique of vesicourethral anastomosis and report their method of objective evaluation of postoperative urinary continence. At the 6th postoperative week, 15% of patients presented with severe incontinence. This percentage fell to 3.3% by the 16th postoperative week.

Characteristics and expectations of patients with erectile dysfunction: results of the SCORED study.

In an observational study in men with erectile dysfunction (ED) consulting a general practitioner (GP) or urologist in Belgium, demographics, ED characteristics (including erection hardness score), co-morbidities and treatment expectations were evaluated using a structured questionnaire. In total, 341 GPs and 41 urologists recruited 1492 patients. Most (74%) were untreated and 25% had ED for >3 years. Considering PDE5 inhibitors, erection hardness (89%) and maintenance (92%) were considered 'very important' by most patients. Only 18% of physicians initiated discussion about ED, despite 41% of patients having >or=3 known risk factors. The questionnaire was considered helpful by 81% of GPs and 83% of their patients. Overall, patients are under-diagnosed, and physicians are reluctant to ask about ED. A questionnaire including erection hardness score is useful to facilitate discussion about ED in general practice. Erection hardness and maintenance are more important to patients as compared to fast onset or long duration of action.

Female urinary incontinence: imaging by or for the urologist.

The author reviews the imaging techniques useful in the evaluation of female urinary incontinence: voiding cystourethrography and videoradiourodynamics. Voiding cystourethrography allows to disclose two forms of bladder base suspension defects: anterior and posterior suspension defects. It will be performed before surgery. Videoradiourodynamics will be limited to patients with recurrent urinary incontinence following unsuccessful surgery.

Treatment of erectile dysfunction.

The evaluation and treatment of Erectile Dysfunction has evolved dramatically over the last 10 years thanks to the improvement of our understanding of the physiology of erection and the development of effective drugs to be taken "on demand" before intercourse. In addition, Erectile Dysfunction is now clearly recognized as a medical disorder. It is beyond the scope of this article to go into details about the physiology and pathophysiology of the sexual cycle and the different diagnostic procedures for evaluating erectile disorders. Rather, we will concentrate on the therapeutic options for managing erectile disorders after a brief review of the most recent concepts of erection physiology and diagnosis.

Bit-mapped imaging of somatosensory evoked potentials after stimulation of the posterior tibial nerves and dorsal nerve of the penis/clitoris.

Somatosensory evoked potentials (SEPs) to unilateral or bilateral posterior tibial nerve (PTN) stimulation and to stimulation of the dorsal nerve (DN) of the penis/clitoris were recorded on 32 channels in 10 volunteers. SEPs to unilateral PTN stimulation consisted of the classic 'W' complex P38-N45-P56-N75 maximal on the ipsilateral central and parietal leads, and two negative waves, N33 and N37, maximal on the contralateral post- and prerolandic areas, respectively. A lemniscal P30 was also recorded. Bilateral PTN stimulation caused, by algebraic summation, the disappearance of both N33 and N37; the W complex was symmetrical and the amplitude of P30 increased. The SEPs to DN stimulation were also symmetrical, and N33 and N37 were absent. These features can be explained by the bilateral character of DN stimulation. They also differed from bilateral PTN SEPs in 3 respects; the absence of P30, the small amplitude and the weaker gradients of field distribution of the 'W' complex, and the somewhat different distribution of penile from clitoral or bilateral PTN, N45 and P56. These differences can be explained both by physiological (the different fiber composition of the DN) and anatomical (the deeper localization of the DN cortical receiving area) mechanisms.

Treatment of advanced carcinoma of the prostate with a depot luteinizing hormone-releasing hormone analogue (ICI-118630).

We treated 37 patients with newly diagnosed advanced prostatic cancer with monthly injections of a long acting depot preparation of a luteinizing hormone-releasing hormone superagonist. Serum testosterone levels were reduced to and maintained within the castrate range, even in cases of objective progression. The partial objective regression rate was 43 per cent, with 36 per cent of the patients having objectively stable disease and 21 per cent having objective progression. The subjective improvement rate was 67 per cent. The addition of a short course of diethylstilbestrol at the initiation of therapy appeared to shorten the delay for the subjective improvement. Patient acceptance was excellent and side effects were minimal. Depot luteinizing hormone-releasing hormone analogues, alone or in combination, may well become a preferred alternative treatment for patients with advanced prostatic cancer.

[Sympathetic evoked potentials of the perineum]. / Les potentiels évoqués sympathiques du périnée.

The authors describe the principles and indications of sympathetic evoked potentials recorded from the pelvic floor. The technique consists of an electrical stimulation of a somatic nerve (median nerve at the wrist or dorsal nerve of penis) with recording of the electrical activity induced by the sympathetic nerve terminals of the sweat glands from the perineal skin, using surface electrodes.