[Botulinum A toxin and detrusor sphincter dyssynergia: retrospective study of 47 patients]. / Toxine botulique A et dyssynergie vésico-sphinctérienne : étude rétrospective portant sur 47 patients.

INTRODUCTION: To assess the efficacy of injections of botulinum toxin type A (BT-A) in the urethral sphincter for treating detrusor sphincter dyssynergia (DSD). PATIENTS AND METHODS: Retrospective observational study of patients with confirmed urodynamic DSD (neurological and non-neurological etiologies) treated at our center from 2002 to 2010. All patients received 300 IU of DYSPORT® injected transperineally under electromyographic control. Using a visual analog scale (VAS) for mictional disorders and the measure of the post-void residual (PVR) as criteria of efficacy, results were classified as "non-satisfactory" (decrease in the VAS<2 or decrease in the PVR<20%), "intermediate" (decrease in the VAS≥2 or decrease in the PVR≥20%) or "satisfactory" (decrease in the VAS>3 or decrease in the PVR>40%). RESULTS: Records of 47 patients (7 women and 40 men) were studied. Mean follow-up was 14.2 months. At the end of follow-up, there were 23.4% (11) of "satisfactory" results, 19.1% (9) of "intermediate" results, 42.6% (20) of "non-satisfactory" results and 14.9% (7) of patients lost for follow-up. The mean decrease in PVR was 60 mL (from an average of 212 to an average of 152 mL). No side effect was observed. CONCLUSION: In this small series reporting the results of the injection of BT-A in the urethral sphincter for DSD, we observed 42.5% of satisfactory or intermediate results without associated side effects.

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.

[Abdominal management of rectocele and elytrocele: place of the laparoscopic approach]. / Traitement des rectocèles et des élytrocèles par voie abdominale: apport de la laparoscopie.

AIM OF THE STUDY: To report the results of abdominal promontory rectopexy and douglassectomy in the management of rectocele and enterocele. PATIENTS AND METHODS: Between 1992 and 2002, 72 patients were operated by one colorectal surgeon. Laparotomy was used in 37 cases between 1992 and 2001 and the laparoscopic approach in 35 cases from 1995 to 2002. Promontory rectal fixation required only one mesh secured between the anterolateral right side of the rectum and the lumbosacral ligament. The same mesh was used to fix the vagina or the cervix. Combined therapeutic or prophylactic urinary interventions are frequent in the series. RESULTS: The follow-up was more than one year in 63 patients with a mean value of 58 months with no patient lost. Recurrence of posterior vaginal prolapse was noted in only two cases. Dyschesia and urinary incontinence were improved respectively in 80 and 70% of the cases and a significant improvement in anal incontinence was observed in 95% of the patients. CONCLUSION: The abdominal way allows a suitable treatment in patients with advanced stage rectocele and enterocele and evidence of pelvic organ prolapse. The laparoscopic approach is superior in terms of morbidity and functional results.

[Dyschezia, pudendal neuropathy, and functional pelvico-perineal disorders]. / Dyschésie, neuropathie pudendale et troubles fonctionnels pelvi-périnéaux.

A critical literature review allows an analysis on chronic constipation evaluation and on the association with anatomical or functional pelvic perineal disorders, the link with a pudendal neuropathy being frequent. The dyschezia clinical diagnosis must be completed by X-ray and manometric examinations to well determine the respective part of anatomical and/or functional disturbances. Stretch pudendal neuropathy was first described in association with descending perineum and chronic constipation. This kind of neuropathy is frequently obvious in other pelvic defects, genital prolapses, urinary incontinence, micturition disturbances. The diagnosis must be made with a complete electrophysiological assessment and not only with the pudendal nerve latency terminal motor latency measurement. These pelvic-perineal disorders have plurifactorial aetiologies, they are linked together without univoqual chronology, each one may be the cause or the consequence of the other, and self-worsening evolution may occur.

Influence of a weak hydrogen bond on vibrational coherence probed by photon echoes in DCl dimer trapped in solid nitrogen.

The dynamics in the ground electronic state of the two intramolecular D-Cl stretching modes of (DCl)2 in nitrogen solid has been probed by degenerate four wave mixing experiments. Accumulated photon echoes on the "free" nu1 and "bonded" nu2 modes have been performed by means of the free electron laser of Orsay (CLIO). The analysis of the time-resolved signals provides information on the various processes responsible for the loss of vibrational coherence, in particular intra- and intermolecular vibrational energy transfer and pure dephasing. The influence of the weak hydrogen bond is clearly observed on the coherence times of the two stretching modes. Whatever the temperature, the homogeneous width of nu2 lines is almost twice that of nu1 lines. Contrary to the case of isolated DCl trapped in solid nitrogen, no obvious effect of the nitrogen lattice can be extracted from the temperature dependence of the coherence times.

[Urinary incontinence and prolapse. Medical treatment and functional treatment]. / Incontinence urinaire et prolapsus. Traitement médicamenteux et traitement fonctionnel.

Urinary continence implies that the variations of the vesical pressure does not exceed the capacities of the cervico-urethral closure system. The aim of the various methods of treatment is to have a beneficial action on those two parameters: drug therapy will mainly reduce the intra-vesical pressure (parasympatholytics...) and also improve the urethral tone (alpha-adrenergics...), or have a mixed effect on both systems (tricyclic antidepressants, oestrogens...). The side effects are often numerous due to the impact on the vegetative or neuromuscular system. The re-education is complemented by: local and general kinesitherapy, sensorial retrocontrol, associated or not to electrotherapy. Motivation and active participation of the patient are essential. The indications covers all the various pathologies (perineal insufficiency, defects in the body pattern, prolapse, sphincteral insufficiency, transmission problems, vesical instability, urethral instability) and concerns patients of all age groups.

[Rehabilitation during pregnancy and in the postpartum]. / La rééducation pendant la grossesse et dans le post-partum.

Pregnancy and labour are notable etiopathogenic factors concerning urinary incontinence and pelvic positional problems. 30 to 40% of women suffer from incontinence during pregnancy and 20% in the post-partum period. While this incontinence regresses spontaneously in 60 to 80% of cases, it nevertheless reflects the existence of pelviperineal problems. Combined with the efforts of everyday life, this trauma finally explains the high incidence of women with urinary problems and pelvic positional difficulties starting from the fourth and fifth decades of life. Perineo-sphincter exercises must be started very early, during the pre-partum phase and always before the start of sports and occupational activities. It involves all the constituents of the lumbo-pelvi-perineal region and in particular perineal tone, muscle power and strength and the quality of sphincter closure during effort. These efforts are themselves studied on the basis of the pressures which they produce. In total, perineal exercises, abdominal exercises and physical activity are not contradictory but, in fact, complementary, such that the management approach is global and adapted to the individual.