[Use of botulinum toxin A in pelvic floor dysfunctions in the elderly: A review]. / Intérêt de la toxine botulinique A dans le traitement des troubles pelvi-périnéaux de la personne âgée.

INTRODUCTION: The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly. METHODS: The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated. RESULTS: Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended. CONCLUSION: BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.

[Cardiovascular adverse effects of antimuscarinics used in the treatment of overactive bladder in the elderly : A review]. / Effets cardio-vasculaires des traitements anticholinergiques à visée vésicale chez la personne âgée : une revue.

AIM: The aim of this study was to review the evidence regarding the cardiovascular effects of urinary anticholinergic drugs in the elderly. METHODS: A literature review was conducted in October 2017 using the Medline/Pubmed database limiting the search to works in English or French. RESULTS: In total, 602 articles between March 1964 and October 2017 have been reported, 60 studies were analyzed, 19 were prospective trials. Geriatric population has a high prevalence of cardiovascular diseases (24.4% of heart diseases on 65-74years and 36.9% on ≥75years). More than 20% of the geriatric population has overactive bladder history and 41.43% of them use of antimuscarinic drugs. Evaluating the cardiovascular adverse effects of antimusarinics in the geriatric population is not easy because of exclusion of high-risk patients in trials. However, serious cardiovascular adverse effects were reported like atrial fibrillation, atrioventricular block or torsade de pointe. Further studies are needed especially in the "real life" in order to precise the exact prevalence of such cardiovascular alterations. CONCLUSION: Without conclusive evidence, potential cardiovascular adverse effects of anticholinergic agents used in overactive bladder must lead to a cautious prescription.

Evidence of a new pattern of ejaculation in men with spinal cord injury: ejaculation dyssynergia and implications for fertility.

OBJECTIVES: To describe the presence of sperm in the prostatic urethra as a stand-alone ejaculation entity and to assess its characteristics. METHODS: Thirty-three patients with anejaculation during sexual stimulation were enroled. Penile vibratory stimulations were carried out following bladder catherization and instillation of a pink buffering medium (Ferticult). Two-step catheterisation was then performed: a catheter was inserted through the urethral sphincter into the prostatic urethra to aspirate its content, and then bladder catheterisation was performed to collect the Ferticult. The procedure was repeated in some patients after at least 1 week. The characteristics of the semen collected from each organ were analysed and compared. RESULTS: A total of 42 trials were obtained from 22 patients. Sperms were found in the prostatic urethra in 21 samples (50%) from 12 patients (11 with spinal cord injury, 1 with diabetes). The colour of all 21 prostatic urethra sperm samples differed from the Ferticult. Sperm motility was greater in 8 samples, sperm count was higher in 10 and pH was different in 10, compared with the bladder samples. The higher overall quality of the sperm allowed cryopreservation in 10 prostatic urethra samples compared with only 5 bladder samples. Four of the five patients who underwent repeated trials had a reproducible pattern of prostatic urethra ejaculation. CONCLUSION: The presence of sperm in the prostatic urethra most probably results from 'ejaculation dyssynergia', a lack of coordination between bladder neck and external sphincter. Sperm from the prostatic urethra should be systematically sought to improve the outcome of assisted reproduction.

[Noxious stimuli and neurogenic overactive bladder]. / Épines irritatives et hyperactivité vésicale neurologique.

OBJECTIVES: Describe the relationships between neurogenic overactive bladder and noxious stimuli. METHODS: Relevant data from the literature were identified primarily through a Medline search of articles published through July 2014. The search terms included overactive bladder, central nervous system, noxious visceral and cutaneous stimuli. RESULTS: Overactive bladder often due to overactive detrusor is the most common symptom observed in central neurogenic bladder (70 to 80% in case of spinal cord injury). Pathophysiological mechanisms are various and numerous. Noxious cutaneous stimuli may determine, or maintain, these symptoms by increased afferent inputs in segmental levels, particularly S2S3 levels, determining exaggerated visceral, muscle and bladder responses depending on this considered medullary level. These modifications are only observed in case of central neurogenic lesions secondary to spinal cord involvement. Animal researches have precised the role of lack of the supra-segmental inhibition. CONCLUSIONS: In presence of neurogenic overactive bladder, it is always necessary to track down noxious stimuli particularly in case of modifications of clinical or urodynamic status or when the usual treatments, generally anticholinergic drugs, have a reduced efficacy. Treatment is first focused on the suppression of these noxious cutaneous stimuli.

[Sexuality of men with neurologic disorders]. / Sexualité du patient neurologique.

INTRODUCTION: Neurological disorders affecting the brain, the spinal cord or the peripheral nervous system are frequently responsible for sexual disorders. Their impact can be major and could rank first in the concerns of patients with neurological handicap, particularly those who are paraplegic. METHODS: Medical literature was reviewed and combined with expert opinion of the authors. RESULTS: Sexual dysfunction can vary depending on the site of the lesion, its complete or incompleteness for the spinal cord, its natural history, the age of onset. Value of the data present in the literature varies depending on the pathology. Many neurological patients are on medication and an iatrogenic factor is not to be excluded when managing and understanding the physiopathology of sexual dysfunction. Clinical trials evaluating the efficacy of pharmacological treatments are often specific to one pathology. This means that extrapolating to other neurological disorders is difficult and could even be dangerous in the presence of orthostatic hypotension. Due to the vicinity of the spinal centers controlling bladder, sphincteric, anorectal and sexual functions the symptomatology is often mixed associating urinary, sexual and fecal disorders. The treatment of urinary incontinence and management of anorectal disorders should precede the treatment for sexual complaints. The existence of a sexual disorder can be of great help in the neurological diagnosis in certain contexts (extrapyramidal syndromes). We report the data from the literature concerning male sexual disorders in cases of acquired brain lesions (stroke, cranial trauma), extrapyramidal symptoms, medullar lesions, multiple sclerosis, peripheral lesions of the cauda equina or more distal. CONCLUSION: Sexual dysfunction must be part of the overall management of neurological patients.

[Management of neurogenic bladder patients in France: a survey carried out by the French-speaking neurourology study group (GENULF)]. / Prise en charge des patients ayant une vessie neurologique en France: une enquête du groupe d'études de neuro-urologie de langue française (GENULF).

OBJECTIVE: To design and run a survey aiming at investigating urologists' and physiatrists' clinical practices in France when managing neurogenic bladder patients. PATIENTS AND METHODS: Three thousand one hundred and eighty questionnaires were sent to the members of four French societies involved in treating neurogenic bladder dysfunction. Questions were focused on consultations, clinical follow-up and patient management. RESULTS: Two hundred and seventy-four urologists and 109 physiatrists completed the questionnaire. The frequency of systematic follow-up differed between urologists (6 months) and physiatrists (12 months). Upper urinary tract imaging and systematic urodynamic follow-up were usually performed yearly. The latter was carried out by 56% urologists and 83% physiatrists. Urinary retention was essentially treated by intermittent catheterization. Less than 15% of urologists and physiatrists were treating bacteriuria. Symptomatic urinary infections were treated for 11 to 12 days (men) and for 8 to 9 days (women). To treat their patients, both specialists used self-catheterization education and botulinum toxin A injections. CONCLUSION: Our survey showed differences in approach between urologists and physiatrists in the management of patients with neurogenic bladder dysfunction. Their clinical practice was most of the time in line with national and international guidelines.

[Criteria and best clinical practice guidelines for first intradetrusor injection of botulinum toxin type A to treat neurogenic detrusor overactivity]. / Critères de décision et recommandations de bonne pratique clinique pour la première injection intradétrusorienne de toxine botulique A dans le traitement de l'hyperactivité neurogène du détrusor.

Botulinum toxin A intradetrusor injections have revolutionised the treatment of neurogenic detrusor overactivity. Based on a systematic literature review, the french speaking group of neuro-urology (Genulf) propose clinical guidelines concerning the indications of the first injection.

[Patient follow-up after botulinum toxin intradetrusor injection. Proposal for management in neurogenic patients]. / Suivi des patients après injection de toxine botulique intradétrusorienne Recommandations de bonne pratique clinique chez le patient neurologique.

Injections of botulinum toxin into the detrusor is a major evolution for treatment of neurogenic bladder. They are now considered as a treatment of choice, safe and efficient, in refractory neurogenic overactivity in catheterized patient. To date, there are no consensual practical guidelines for the follow-up of patients having been treated by intradetrusor botulinum toxin, whatever the indication of the treatment, functional, that is, for improving continence and overactive bladder syndrome or organic, that is, for treatment of high-detrusor pressure and their deleterious impact of urinary tract. This lack of guidelines leads to heterogeneity of treatment management and limit the definition of optimal modalities of intradetrusor botulinum toxin treatment in neurogenic patients. The aim of your work, prepared jointly with the International Francophone Neuro-Urological expert study group (GENULF), aimed at putting forward well-informed specific recommendations for the follow-up of patients having been treated by intradetrusor botulinum toxin for functional or organic indication of neurogenic detrusor overactivity.

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.

The isolated sympathetic spinal cord: Cardiovascular and sudomotor assessment in spinal cord injury patients: A literature survey.

OBJECTIVES: To present a comprehensive approach to the assessment of the severity of the autonomic lesion in spinal cord injury (SCI) patients, with regard to the level of lesion. To discuss how to assess an isolated sympathetic spinal cord that has lost supraspinal control (sympathetically complete lesion). METHOD: PubMed was searched for articles related to cardiovascular (mainly cold pressor test, respiratory and postural challenges) and sudomotor (sympathetic skin responses) tests that have been used. The results of these evaluations are analysed with regard to the site of stimulation (above or below the lesion) according to three types of SCI that offer typical autonomic reactions (tetraplegics, paraplegics at T6 and at T10). RESULTS: Non-invasive cardiovascular and sudomotor testing allows the assessment of the isolated sympathetic spinal cord in SCI patients. Typical responses are found in relation with the level of the sympathetic lesion. Its definition would allow comparison with the somatic motor and sensory level of lesion of SCI patients and provide additional aid to the classification of those patients. CONCLUSION: For research purposes on the integrity of the spinal sympathetic pathways, a battery of test approach is probably needed, using a combination of stimuli above and below the lesion, evaluating both cardiovascular and sudomotor pathways.