[Seniority of neurobladder and effectiveness of a first intradetrusor injection of botulinum toxin]. / Ancienneté de la neurovessie et efficacité d'une première injection de toxine botulique intradétrusorienne.

UNLABELLED: Intradetrusor injection of botulinum toxin is one of the second-line therapy of neurologenic detrusor overactivity. GOAL OF THE STUDY: In 26% to 66% of the cases, intradetrusor injection of botulinum toxin is inefficient in order to reduce overactive bladder symptoms and/or overactive detrusor. The objective of this study is to determine whether it exists a link between the efficacy of the first IDBT and the length of neurological detrusor overactivity symptoms. METHODS: Retrospective study on 79 patients which have a first intradetrusor injection of botulinum toxin between January 2001 and December 2013. Inclusion criteria were patients older than 18 and having neurological detrusor overactivity. RESULTS: There is no significant difference of intradetrusor injection of botulinum toxin efficacy according to duration of urinary symptoms in the general neurologigal population (multiple sclerosis, spinal cord injury, spinal cord compression, ischemic pathology, infectious pathology) with the mean age being 46 years. On the contrary, the length of evolution of neurological detrusor overactivity symptoms before the intradetrusor botox injection therapy and the efficiency of the first intradetrusor injection of botulinum toxin seem to be correlated with negative results in patients with multiple sclerosis. CONCLUSIONS: The duration of urinary symptoms is a predictive factor of primary failure of intradetrusor injection of botulinum toxin in multiple sclerosis patients, in univariate analysis.

[Lazy bladder syndrome: review of 126 cases]. / Mégavessie congénitale: analyse clinique et urodynamique de 126 cas.

PURPOSE: The lazy bladder syndrome (LBS) is characterized by an infrequent voiding, a large bladder capacity without neurological or urological disorders. In spite of being relatively common, there is little literature about it. The aim of our study was to compare the clinical features and urodynamic findings in asymptomatic or symptomatic patients with lazy bladder syndrome. PATIENTS AND METHODS: We reviewed the charts of 126 adult patients diagnosed with lazy bladder syndrome. Clinical and radiological features, urodynamic findings and therapeutic management were evaluated. With these data, we divided patients into 2 groups: asymptomatic and symptomatic patients. After, we performed a comparative analysis of the data. RESULTS: The incident of LBS was significantly higher in women (81%). Twenty-one patients were asymptomatic (17%), 105 patients were symptomatic (83%). The patients with symptomatic LBS were significantly older (54.3 years ± 14.7). Voiding dysfunction (53%) and urinary retention (27%) were the most common symptoms in symptomatic group. In the uroflowmetry test, maximum and mean uroflow were significantly higher in asymptomatic group (P=0.0074). Reduced bladder sensation revealed no difference in the 2 groups, but in the symptomatic group, detrusor has also a poor contractility (P=0.0001). Nineteen patients (18%) had uro-nephrological complications. CONCLUSION: LBS is certainly underestimated. Voiding dysfunction, urinary retention in infrequent voiders or uro-nephrological complication (urinary tract infection with fever, ureteral reflux…) should recall LBS diagnosis. The hypothesis of bladder structural failure or autonomic nervous system dysfunction may be discussed (suggested). LEVEL OF EVIDENCE: 5.

[Bacterial ecology and resistance to antibiotics in patients with neurogenic overactive bladder treated with intravesical botulinum toxin injections]. / Écologie bactérienne et profils de résistance aux antibiotiques chez les patients avec hyperactivité du détrusor d'origine neurologique, traités par injections de toxine botulique intradétrusoriennes.

INTRODUCTION: For the last ten years, botulinum neurotoxin type A has become the gold standard for the treatment of neurogenic overactive detrusor. Bacterial colonization is common for these patients using clean intermittent self-catheterization, and toxin injections are at risk of urinary tract infections. OBJECTIVES: The aim of our study was to determine the prevalence of different germs and their resistance to antibiotics in patients with neurogenic bladder, treated with intravesical botulinum toxin injections. MATERIAL AND METHOD: This epidemiologic study took place from September to October 2012 in a urodynamic and neurourology unit in a teaching hospital in Paris, France. RESULTS: Eighty patients with a valid urine culture according to our protocol, were included. Fourty-four culture were positive with 45 bacteria. We found an Escherichia coli in 42.5%, a Klebsiella pneumoniae in 7.5%, a Citrobacter freundii and an enterococcus in 2.5%, and a Staphylococcus aureus in 1.25%. Penicillin resistance were found in 51.11%, 3rd generation cephalosporins in 8.89%, quinolones in 28.89% and sulfamids in 24.44%. None were resistant to fosfomycin. CONCLUSION: E. coli was the most frequent bacterium. No resistance to fosfomycin was found.

[Clinical and electrophysiological study of sensory penile alterations. A prospective study of 44 cases]. / Analyse clinique et neurophysiologique des troubles de la sensibilité pénienne. Étude prospective de 44 cas.

OBJECTIVE: To precise clinical presentations, pathophysiology and etiologies of penile sensory alteration. METHODS: Forty-four patients with penile sensory dysfunction underwent clinical and electrophysiological testing with electromyography of bulbocavernosus muscles, study of sacral reflex latencies, somatosensory cortical responses following stimulation of the dorsal nerve of the penis, sensory velocity of the dorsal nerve and pudendal nerve terminal sensory latencies. RESULTS: Penile anesthesia was observed in six (13%) patients, loss of sensibility in 34 (77%), paresthesia in four (9%). Erectile dysfunction was noted in 19 (43%) patients, hypo-orgasmia in seven (16%), cold glans penis sensation in four and loss of spatial sensation during intercourse in three (7%). Abnormalities of electrophysiological perineal testing were observed in 17 (38%) patients. In 27 (62%) cases, no alteration of electrophysiological testing was observed. In 17 (38%) patients, a specific aetiology was founded by means nerve palsy during orthopedic surgery in five cases, entrapment neuropathy following byking in nine cases, two La Peyronie diseases and one diabetes mellitus. CONCLUSION: In the current series, the prevalence of neuropathy of the dorsal nerve of the penis (that can determine a loss of sensibility) was 40%.

Stand up urgency: is this symptom related to a urethral mechanism?

OBJECTIVE: To study the role of women's position as a stimulus of urgency, and specifically the change of position, i.e. to stand up form a lying or sitting position. Thus, we compared clinical and urodynamics characteristics among women with overactive bladder syndrome (OAB) depending of the position which could trigger urgency. METHODS: Thirty-eight females with complaints of urgency, without urinary infection, neurological or urological diseases, were prospectively enrolled. Patients completed a study-specific questionnaire asking about urgency and urge incontinence when in three different positions (standing up, sitting, and standing position). We named stand up urgency (SUU) an urgency, which was defined thanks to this questionnaire, according to the presence of urgency triggered by the change from sitting or lying to a standing position. All patients underwent cystometry in the standing position, urethral closure pressure measurement (MUCP) and Valsalva leak point pressure (VLPP) tests. Urodynamics characteristics were compared in the groups defined by the questionnaire. RESULTS: SUU was associated with lower MUCP (57 vs. 77 cm H(2)O; P=0.017), but not with positive VLPP or DO. Among females with SUU, those with stand up urge incontinence (SUUI) also had lower MUCP (46 vs. 73 cm H(2)O; P=0.019) and more positive cough stress tests (73 vs. 13%; P=0.019). Conversely, urge incontinence in the sitting position was associated with DO (46% vs. 0%; P=0.02), but not with lower MUCP or positive VLPP. CONCLUSION: SUU appeared to be related to impaired urethral closure mechanisms (lower MUCP), but future studies are needed to confirm this hypothesis.

[Evidence of pudendal neuropathy in Proctalgia Fugax: perineal neurophysiological assessment in 55 patients]. / Proctalgies fugaces et neuropathie pudendale : étude neurophysiologique périnéale chez 55 patients.

OBJECTIVE: Proctalgia fugax (PF) is a very common condition especially in women. Causes and pathophysiological mechanisms of PF are unknown. Recently, a pudendal neuropathy was clinically suspected in women with PF. The goal of our study was to demonstrate, or not, such abnormalities by means electrophysiological testing. PATIENTS AND METHODS: Fifty-five patients with PF (45 female and 10 male, mean age 50.2 years) were evaluated. EMG testing with motor unit potential analysis of pelvic floor muscles (bulbocavernosus muscle and striated external anal sphincter), study of bulbocavernosus reflex and pudendal nerve terminal motor latencies (PNTML) were performed. RESULTS: EMG testing was altered in two males out of 10 (20%) and 29/45 females (64%). In women, denervation was found bilateral in 25/29 (86%). Sacral latency was delayed in eight out of 29 (bilateral in five cases, unilateral in three cases) and PNTML altered in 17 cases (13 bilateral alteration, four unilateral). A significant difference (P<0.002 Chi(2) test) was demonstrated between male and female concerning pelvic floor muscles denervation. CONCLUSION: Pelvic floor muscles denervation was a common feature in women suffering from PF, due to a stretch bilateral pudendal neuropathy. Distal lesions of the pudendal nerves, principally due to a stretch perineal neuropathy, can be imagined as a factor or co-factor of PF.

Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients.

PURPOSE: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. MATERIALS AND METHODS: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). RESULTS: 77% of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46% of the patients were in the "full success" group. 31% of the patients had a partial improvement. 23% of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). CONCLUSIONS: Despite that a full success was obtained in 46% of the cases, BTX-A injection therapy failed to treat refractory NDO in 23% of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anti cholinergic drugs fail to reduce NDO.

[Urinary disorders associated with bilharziasis. Urodynamic evaluation. Findings in 10 cases]. / Troubles vésico-sphinctériens des bilharzioses. Etude urodynamique. A propos de 10 cas.

UNLABELLED: Bilharziasis urinary disorders are characterized by recurent hematuria, overactive bladder symptoms (urgency, frequency and urge incontinence) and sometimes weak stream with or without urinary retention. We report 10 cases of urodynamic assessment. RESULTS: The main urodynamic symptom was overactive detrusor with uninhibited detrusor contraction during the filling phase. Only 1 patient had underactive detrusor leading to urinary retention. Urinary symptoms were secondary to a neurogenic abnormality (spinal lesion) in 2 cases, and to a specific lesion of bladder mucosa in 8 cases. CONCLUSION: Urodynamic investigations are usefull in bilharziasis urinary disorders in order to specify the pathophysiology of urinary symptoms and to point a specific neurogenic (spinal) alteration in the genesis of the urinary symptoms.

[Cerebral vasculitis with aneurysms caused by varicella-zoster virus infection during AIDS: a new clinicoangiographical syndrome]. / Vascularite cérébrale avec sténoses et ectasies due au virus varicelle-zona au cours de l'infection par le VIH : une nouvelle entité compliquant le sida.

We describe three cases of cerebral angiopathy with aneurysms caused by a meningeal varicella-zoster virus infection occurring during AIDS. The clinical picture was rather stereotyped: severe immunocompromission due to HIV infection, ongoing multifocal cerebrovascular disease with territorial infarcts, lymphocytic meningitis with normal glucose content (two cases) or hypoglycorrhachia (one case), multifocal cerebral vasculopathy with narrowings and aneurysms, healing with or without neurological sequelae after intravenous aciclovir treatment. The diagnosis of varicella-zoster virus-induced angiopathy was ascertained by the positive specific PCR in the CSF in the three cases and by the results of the cerebromeningeal biopsy in one case. Although, varicella-zoster virus is already known as a cause of cerebral angiopathy both in the immunocompetent and the immunocompromised, these three cases are the first ever described of a particular angiopathy with narrowings and ectasias complicating AIDS. The infectious treatable cause and the risk of aggravation without treatment require early active oriented investigations in case of a patient with cerebrovascular disease occurring during HIV infection, including a CSF study with varicella-zoster PCR, to allow specific antiviral treatment. In our three cases, aciclovir intravenous treatment (30mg/kg per day) enabled VZ virus clearing from the CSF and stopped the course of the vasculopathy.

Validation of the InCaSaQ, a new tool for the evaluation of patient satisfaction with clean intermittent self-catheterization.

AIMS: In neurourology, the choice of catheter is of paramount importance. At the time of our study, no simple validated questionnaire has been published, evaluating patient satisfaction with the use of urinary catheters. Our objective was to construct and validate a specific tool referred to as the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ), for the purposes of evaluating patient satisfaction with intermittent self-catheterization. METHODS: A simple tool was developed and validated in a neurourology referral centre, with 113 patients affected by a neurological bladder condition, between November 2011 and February 2012. Eight items, separated into four categories ("packaging", "lubrication", "catheter itself", "after catheterization") were selected. The mean score obtained with the eight-question questionnaire was calculated for each patient. Face validity was evaluated. Reliability based on internal consistency and test-retest reliability using the intraclass correlation coefficient (ICC) was carried out. RESULTS: The patients' comprehension and acceptance of the questionnaire were good. The questionnaire appears to have been well designed, with a significant Cronbach's alpha coefficient, and the ICC demonstrated good test-retest reliability. CONCLUSIONS: The InCaSaQ was found to be a valid tool for the evaluation of patient satisfaction with a urinary catheter. It is thus possible to compare the comfort and effectiveness of different types of catheter, and to objectify the need to change the type of catheter, in cases where patients express their dissatisfaction.

Therapeutic education and intermittent self-catheterization: recommendations for an educational program and a literature review.

PURPOSE: To review the literature and to clarify the recommendations for therapeutic education programs for intermittent self-catheterization. MATERIALS AND METHODS: The literature on Medline, Pubmed, and Cochrane Library, with specific keywords, as well as the recommendations based on expert consensus. RESULTS: Clean intermittent self-catheterization (CICS) is the gold standard for managing chronic urinary retention, which allows the patients to improve their quality of life and to reduce the complications of upper urinary tract infections. Patient education needs to have a structured procedure in order to evaluate the ability to understand, accept and perform CISC. CONCLUSION: Teaching self-catheterization is now well known; nevertheless, the effectiveness of CISC educational therapeutic programs remains to be demonstrated.

Cold perception of the bladder during ice water test. Study on 120 patients.

OBJECTIVE: If the pathophysiology of bladder cooling reflex (BCR) elicited during an ice water test (IWT) is well-known (triggered by activation of cold receptors within the bladder wall supplied by unmyelinated C fiber afferents) and is widely used for the diagnosis of upper motor neurological lesions, the significance of having a perception of cold in the bladder (PCB) during IWT has not been properly defined yet. PATIENT AND METHODS: Hundred and twenty patients undergoing IWT were analyzed and separated into four groups: group 1 (G1): patients with idiopathic overactive bladder syndrome (OAB); group 2 (G2): patients with functional dysuria (difficult urination due to bladder-neck obstruction, or congenital large bladder); group 3 (G3): patients with multiple sclerosis (MS) and group 4 (G4): patients with cauda equina syndrome (CES). All patients had a cystometry and IWT. After performing IWT, the patients were asked specific questions regarding the various sensations experienced during the cystometry and IWT, especially for detecting the presence or not of a cold sensation when their bladder was filling up. RESULTS: Patients with idiopathic OAB had more frequently a PCB than patients with MS (P<0.02). Patients with bladder-neck obstruction were more likely to retain a PCB than patients with CES (P<0.01). Lack of PCB is more frequent in patients with neurological diseases (P<0.001), with a sensitivity of 66% and specificity of 65%. CONCLUSION: Patients without neurological disease have a heightened PCB during the IWT than patients with neurological diseases. The lack of PCB may reflect an alteration of the afferent pathways or spinal reflex pathways or central neural pathways.

Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients

PURPOSE: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. MATERIALS AND METHODS: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). RESULTS: 77 percent of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46 percent of the patients were in the "full success" group. 31 percent of the patients had a partial improvement. 23 percent of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). CONCLUSIONS: Despite that a full success was obtained in 46 percent of the cases, BTX-A injection therapy failed to treat refractory NDO in 23 percent of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anticholinergic drugs fail to reduce NDO.