[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. / Recommandations sur la gestion du risque et la prise en charge urologique du patient adulte atteint de dysraphisme spinal (spina bifida).

INTRODUCTION: Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS: National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS: Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION: Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

[Is pressure transmission quality during cystometry dependent on the type of effort?] / La qualité de transmission des pressions pendant la cystomanométrie est-elle dépendante du type d'effort ?

INTRODUCTION: The International Continence Society (ICS) recommends a control of the good pressure transmission by a coughing effort during cystometry. While poor transmission is sometimes observed in routine practice, other maneuvers can also be proposed. The main objective of this study was to determine if there is a better maneuver to evaluate the pressure transmission ratio between the abdominal cavity and the bladder. METHODS: We performed a prospective, consecutive, single-center study in a tertiary neuro-urology department in 31 subjects. During a cystometry, each patient was asked to perform at 0ml and 100ml of bladder filling, a cough effort, an abdominal push and a Valsalva maneuver controlled by a manometer. The value of the bladder pressure to abdominal pressure ratio was collected manually. The average variations were compared between each maneuver for the same volume of replenishment and between the 2 volumes of replenishment studied. RESULTS: At 0ml of filling, the difference in pressure variation between the Pves and the Pabd is significantly higher during the cough maneuver compared to the Valsalva (P=0.015), which is not found at 100ml of filling. CONCLUSION: During bladder filling, the pressure transmission ratios during the 3 maneuvers are equivalent. Coughing or abdominal thrusting, which are easier to perform than the Valsalva maneuver, should be recommended to check the quality of the recording during cystomanometry.

Short-term reproducibility of cystometry in multiple sclerosis patients.

OBJECTIVE: To assess the reproducibility of detrusor activity cystometric pattern in multiple sclerosis (MS) patients, which is poorly documented in the medical literature, by means of successive filling. METHODS: We conducted a prospective study in MS patients; cystometry was repeated twice at 5minutes of interval if a detrusor overactivity before 300mL of filling was observed. Thus, 3 successive cystometries were analysed. The following characteristics were recorded: detrusor maximum pressure (Pmax), volume at the first involuntary detrusor contraction (IDC), maximum cystometric capacity (MCC), pressure at the first IDC, the existence of an overactive detrusor classified as phasic or terminal. RESULTS: We included 31 patients (19 women and 12 men); only 6 patients were naïve-treatment, the mean EDSS was: 5.3 (±1.6) and the mean age was 48.4 (±12.5) years. All the patients had an overactive detrusor for each cystometry. The reproducibility was good for all the parameters (range ICC between 0.7 and 0.83). CONCLUSION: Quantitative and qualitative cystometric data have a good reproducibility in MS patients with detrusor overactivity before 300mL of filling. LEVEL OF PROOF: 3.

[Concepts and assessment methods in lower urinary tract symptoms: From symptom score to Patient-Reported Outcomes and Outcomes (PRO)]. / Concepts et méthodes d'évaluation en pelvi périnéologie : du score de symptômes aux attentes et résultats rapportés par les patients (PRO).

INTRODUCTION: The evaluation of pelvic perineal treatments has changed significantly in recent years. Initially focused on the assessment of symptoms, quality of life or patient satisfaction, it has gradually turned to new concepts, such as Patient Reported Outcome (PRO) and Goal Attainment (GA). OBJECTIVE: To describe the different concepts and methods of assessment available, in recent years, in the context of urinary functional pathologies such as bladder overactivity or urinary incontinence. METHODS: We conducted a non-systematic literature review to identify the main questionnaires and tools available to evaluate treatment outcomes. Oncology and pediatrics questionnaire has been excluded. RESULTS: In functional pathology (overactive bladder or incontinence), the objective of treatment is to meet the expectations of patients and it is important to be able to assess the feelings of patients. In this context, new specific questionnaires have been developed to evaluate the PROs. For about ten years, these subjective criteria, are more and more widespread in the evaluation of treatments. A new field then appeared, namely Goal Attainment Scaling (GAS) and Self Appreciation Goal Attainment (SAGA), allowing to determine with the patient, the expected objectives of the treatment. CONCLUSION: These concepts of PRO and GAS open up a new domain in the evaluation of treatments, with a subjective view of the results. They deserve to be integrated into the usual, objective evaluations, in order to adapt the treatment of the patients, according to the real impact of the treatment.

[Vaginal gas: Review]. / Gaz vaginaux : revue de la littérature.

OBJECTIVE: The aim of this article was to review the literature about vaginal winds (VW). METHODS: A literature review (Medline database, Cochrane Library and Google scholar) with no time limit was performed using keywords "vaginal winds", "vaginal noise", "vaginal gaz", "flatus vaginalis", "vaginal flatus", "colpophony", "Garrulitas vulvae", "vaginal laxity". RESULTS: From 412 articles about VW, 15 have been selected and 99 from 110 about vaginal laxity. VW occurs during physical exercises but also during and just after coïtus. The prevalence is about 20%. The pathophyiology of VW is probably a vaginal hyperlaxity itself secondary to pelvic floor muscles weakness and thus increased diameter of vaginal hiatus. VW alter sexual function in female patients but this sexual function seems not influenced in male partners. Tampons or pessaries are currently the most commonly proposed treatment (but naturally impossible to use during sexual intercourse), but some results from vaginal laser therapy are encouraging. CONCLUSION: Data from the literature suggest that vaginal winds are frequent and seriously impact quality of life of female patients. Childbirth and more generally vaginal laxity are the main causes. Pelvic-floor exercises, tampons, pessaries, surgery and laser can be proposed in order to improve sexual function in patients seeking treatment.

[Menthol in the control of bladder activity: A review]. / Le menthol dans le contrôle de l'activité de la vessie : revue de littérature.

INTRODUCTION: Menthol is a natural compound, of which the known effects on human physiology are manifold (a feeling of freshness, decongestant, bowel antispasmodic). Its implication in vesico-sphincteral physiopathology has been studied since the nineties. METHOD: Literature review of the previous studies having implied menthol in pelvi-perineal physiology through the articles indexed on the Pubmed database, with keywords menthol, menthol and bladder, menthol and toxicity, and TRPM8. Only articles in English were selected. RESULTS: Of the 30 articles that were included, most demonstrated the existence of a micturition reflex to menthol and cold, mediated by the C-type nerve to the spine through activation of TRPM8 urothelial receptors. More recent experiments paradoxically showed an inhibitory effect of menthol on detrusor contractility, independently of TRPM8, when muscle tissue is directly exposed to the compound. However, similar effects of targeted cutaneous exposure or urothelial exposure on detrusorian function have also been demonstrated through TRPM8. This receptor also appears to be involved in interstitial cystitis and idiopathic detrusor overactivity. Lastly, the potential toxicity of menthol appears negligible. Most of the referenced studies are related to animal experiments. Of the three studies that implied humans, only one elucidates some therapeutic applications. CONCLUSION: It seems that menthol and its receptors are involved in vesico-sphincteral physiopathology and could provide therapeutic potential in detrusorian overactivity and interstitial cystitis with reduced toxicity.

Emptying cystometry: A feasibility and validation pilot study on female patients.

INTRODUCTION: To assess the feasibility and the accuracy of emptying cystometry in order to simplify the manometric follow-up of overactive detrusor in neurological patients under anticholinergic or botulinum toxin injections. MATERIAL: Female patients with a stable detrusor underwent both a conventional cystometry and sequential measurements of bladder pressure during emptying (emptying cystometry). At the end of the standard cystometry, a CH12 urinary catheter was introduced in the bladder and was connected to a three-way stopcock. The second way of the stopcock permitted the emptying. The third way of the stopcock was connected to a vertical graduated tube to measure the bladder pressure each 50mL during the bladder emptying. RESULTS: Eleven female patients were included (mean age: 59.4years). Nine patients (82%) had neurogenic bladder. Mean cystometric capacity was 439mL (SD: 35mL). During the emptying cystometry, 8 to 10 measures were taken (mean: 9.4). The mean detrusor pressure was 1.7cmH2O (SD 2.1) for the filling cystometry and 2.3cmH2O (SD: 2.7) for the emptying cystometry. The agreement between the detrusor pressure between the two cystometries was good with intra-class correlation coefficient at 0.66 [0.48-0.77] - and the correlation was high (r=0.7; P<0.000001). CONCLUSION: In a small, selected sample of patients, emptying cystometry provides similar results of detrusor pressure to filling cystometry. This technique could constitute a home monitoring of bladder pressures in a selected population of patients with intermittent catheterization in whom a manometric follow-up of detrusor overactivity is required. LEVEL OF EVIDENCE: 4.

[Self-intermittent-catheterization and urinary retentions in Parkinsonian syndromes]. / Auto-sondages intermittents et rétentions urinaires des syndromes parkinsoniens.

INTRODUCTION: Lower urinary tract symptoms are common in Parkinson diseases, especially chronic urinary retention. In case of significant and symptomatic postvoid residual, a specific treatment is necessary in order to empty the bladder and nowadays the gold standard of such neurogenic bladder is based on self-intermittent-catheterizations, if possible at all. We carried out a retrospective study about feasibility and outcomes of self-intermittent-catheterizations in this population. METHODS: Retrospective study with qualitative and quantitative, clinical and instrumental (urodynamic) assessment, of lower urinary tract symptoms as urinary retention in extrapyramidal syndromes. RESULTS: Overall, 42 patients with parkinsonian syndrome performing self-intermittent-catheterization were assessed. Twenty-one had idiopathic Parkinson's disease, 17 multiple system atrophy, 1 vascular Parkinson, 1 iatrogenic Parkinson and 2 not yet determined parkinsonian syndromes. All the patients had urinary retention characterized by a postvoiding residual volume more than 150mL. All the patients were symptomatic and reported voiding dysfunction (30/42), overactive bladder syndrome (20/42), stress urinary incontinence (6/42). The cystometry showed detrusor overactivity (15/42), bladder-sphincter dyssynergia (15/42), detrusor underactivity (14/42), sphincter deficiency (4/42) or bladder compliance alteration (3/42). Each patient have learned and well controlled self-intermittent-catheterization technique. Fourteen (33%) stopped self-intermittent-catheterization prematurely in the following months because of functional impact of neurological worsening. CONCLUSION: Even if one third of the patients had stopped self-intermittent-catheterization because of neurological deterioration, this technique remains the gold standard for the treatment of urinary chronic retention in parkinsonian patients. LEVEL OF EVIDENCE: 4.

Solifenacin is effective and well tolerated in patients with neurogenic detrusor overactivity: Results from the double-blind, randomized, active- and placebo-controlled SONIC urodynamic study.

AIMS: To investigate the effect on urodynamics of 4 weeks treatment with solifenacin succinate in patients with neurogenic detrusor overactivity (NDO) due to multiple sclerosis (MS) or spinal cord injury (SCI). METHODS: SONIC was a prospective, multicenter, double-blind, phase 3b/4 study investigating the efficacy and safety of solifenacin 10 mg in patients with NDO due to MS or SCI. Patients (n = 189) were randomized to placebo or active treatment (solifenacin 5 mg, 10 mg or oxybutynin hydrochloride 15 mg) for 4 weeks, after a 2-week, single-blind, placebo run-in period. The primary endpoint was change in maximum cystometric capacity (MCC) from baseline to end of treatment. The primary analysis compared solifenacin 10 mg versus placebo; all other comparisons were considered secondary. Secondary endpoints included changes in urodynamic parameters, patient-reported outcomes, and safety assessments. RESULTS: In the primary analysis, solifenacin 10 mg significantly improved mean change from baseline MCC versus placebo (P < 0.001) and was associated with improvements in bladder volume at first contraction and at first leak as well as detrusor pressure at first leak. Similar results were obtained for oxybutynin versus placebo. Patient perception of bladder condition significantly improved with solifenacin 10 mg versus placebo (P = 0.041). There was a clear improvement in quality of life (QoL) in the solifenacin arms versus placebo. The overall incidence of adverse events was low. CONCLUSIONS: In patients with NDO due to MS and SCI, 4 weeks of treatment with solifenacin 10 mg improved urodynamic variables and QoL versus placebo and was well tolerated. Neurourol. Urodynam. 36:414-421, 2017. © 2015 Wiley Periodicals, Inc.

[Urethral meatus deformities and urethra hypospadias in women: prevalence, problems and definitions. Study of 12,739 patients]. / Méat urétral enfoui et urètre hypospade chez la femme : prévalence, problématiques et définitions. Étude sur 12 739 patientes.

UNLABELLED: The difficulty to access to the urethral meatus is found in women in relation to morphological abnormalities of urogenital or ectopic locations meatus, whether acquired (urethral meatus buried [UMB]) or congenital reality (urethra hypospadias [UH]). The pathophysiology is not unequivocal with lack of clear and specific studies. PURPOSE: Verify the existence of specific functional problems, assess the prevalence and identify the anatomical features of UMB and UH. MATERIALS: UMB and UH were sought in a computerized database listing the patients attending a neurourology department between 2000 and 2014 for a pelvic-perineal disease. Each case was analysed for specific reached leaks, urinary tract infections and difficulties catheterization. RESULTS: Of the 12,739, 131 patients (1%) met the inclusion criteria, including 18 UH and 113 UMB. Ninety-one patients consulted for urinary disorders of neurological origin. The circumstances of UMB and UH discovery were: perineal systematic review in 63 cases (48%); difficulties of urethral catheterization in 65 cases (49%); urinary incontinence for 3 patients (3%). Urinary tract infections have not led to the discovery of UMB or UH. Difficulties locating the urethral meatus were congenital (UH) in 18 cases (13%). In 113 cases (87%), it was an acquired abnormality (UMB) overweight for 16 patients (12%), troublesome spasticity of the adductor muscles in 18 cases (14%), vulvovaginal atrophy in 5 cases (4%) and a patient (1%) with a pelvic organ prolapse. No details were given for the remaining 72 patients (54%). CONCLUSION: The urethral meatus difficult access due to MUE or UH can be met in a specialized service but the exact concept of MUE be defined. It can be considered as urethral meatus difficult to access and the cause is acquired. Functional impairment may be particularly important in patients requiring catheterization for bladder emptying. LEVEL OF EVIDENCE: 4.

[Intra-detrusor injection of botulinum toxin for female refractory idiopathic overactive bladder syndrome]. / Injections intra-détrusoriennes de toxine botulinique pour l'hyperactivité vésicale idiopathique réfractaire de la femme.

INTRODUCTION: Botulinum toxin-A detrusor injections are now approved for use (extension of marketing authorization) in the management of refractory idiopathic overactive bladder. The goal of the current study was to study the value and efficacy of this therapy. PATIENTS AND METHODS: A literature review was performed on Medline, Embase and Cochrane databases, using the following keywords: botulinum toxin; overactive bladder syndrome; urinary incontinence; detrusor injection. RESULTS: The recommended first step dose is 50 units of BOTOX(©) (dose selected for tolerance assessment). However, the cure rates for urge incontinence are greater with 100 units. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by the patient, because of the risk of urinary retention (6%). The administration of BOTOX(©) comprises an intra-detrusor injection using a cystoscope, performed under local anesthesia. Clinical improvement is generally observed in the first two weeks after the injection. Patients should be considered for reinjection when the clinical effect of the previous injection has diminished, approximately 6-9 months after the first injection. An injection of 100 units may be considered when the clinical benefit of the 50-unit injection is not satisfactory concerning incontinence symptoms. CONCLUSION: Botulinum toxin detrusor injections may be offered to women who develop refractory OAB.

[Guidelines concerning urinary incontinence in elderly: construction and validation of GRAPPPA algorithm]. / Recommandations concernant l'incontinence urinaire de la personne âgée : construction et validation de l'algorithme décisionnel GRAPPPA.

OBJECTIVES: Provide guidelines presented as an algorithm for practical evaluation and first line therapy of urinary incontinence in elderly. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 40 experts quoting proposals, subsequently reviewed by an independent group of multidisciplinary experts (urologist, general practitioner, neurologist, gynecologist, geriatrist, specialist in physical medicine and rehabilitation). RESULTS: By means of 3 rounds of interrogation of the expert panel, GRAPPPA algorithm was constructed. This algorithm take in account both evaluation and first line therapeutic options in the different type of incontinences observed in this population (urge, stress and mixed incontinence). Initial evaluation consists to track down urinary retention (and subsequently fecal stool impaction, use of anticholinergic or morphinic drugs), urinary tract infection and cognitive impairment. Haematuria, bladder-pelvic pain, history of radiotherapy or recent pelvic surgery, lead to refer the patient to a specialized unit. First line therapy is in all the cases pelvic floor training, use of local oestrogenotherapy and dietetic measures. In urge incontinence, anticholinergic drugs may be used. CONCLUSIONS: Implementation of this algorithm may promote best practice in management of urinary incontinence in elderly.

[Guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic overactive bladder management]. / Recommandations pour l'utilisation de la toxine botulinique de type A (Botox®) dans l'hyperactivité vésicale réfractaire idiopathique.

OBJECTIVES: Provide guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic Overactive Bladder management. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 13 experts quoting proposals, subsequently reviewed by an independent group of experts. RESULTS: In the case of patients with urinary tract infection, it must be treated and injection postponed. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by patient. The injection can be performed after local anesthesia of the bladder and urethra (lidocaine), supplemented where necessary by nitrous oxide inhalation and sometimes under general anesthesia. Injection is performed in the operating room or endoscopy suite. The bladder should not be too filled (increased risk of perforation). Treatment should be applied in 10 to 20 injections of 0.5 to 1mL homogeneously distributed in the bladder at a distance from the urethral orifices. It is not recommended to leave a urinary catheter in place except in cases of severe hematuria. The patient should be monitored until resumption of micturition. After the first injection, an appointment must be scheduled within 3 months (micturition diary, uroflowmetry, measurement of residual urine and urine culture). Performance of self-catheterisation should be questioned in the case of a symptomatic post-void residual and/or a residue>200mL. A new injection may be considered when the clinical benefit of the previous injection diminishes (between 6 and 9 months). A period of three months must elapse between each injection. CONCLUSIONS: Implementation of these guidelines may promote best practice usage of BoNTA with optimal risk/benefit ratio.

[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%.

[Contribution of investigations to the diagnosis of bladder outlet obstruction in women]. / Apport des explorations complémentaires au cours du bilan d'une dysurie de la femme.

OBJECTIVE: To study the intrinsic diagnostic value of the exams performed to explore bladder outlet obstruction in women. METHODS: Review of literature (PubMed, Embase, Cochrane Database) using following keywords: female, bladder outlet obstruction, post-void residual, uroflowmetry, flow pattern, cystoscopy, MRI, retrograde cystography, bladder wall thickness, bladder trabeculation, urinary retention, voiding cystometry, pressure flow studies, electromyography. Among 2660 articles (animal and anatomical studies have been excluded), 40 have been selected because they focused on the evaluation of the intrinsic value of exams. RESULTS: The concomitant recording of bladder and abdominal pressure during voiding (pressure flow study) is useful to diagnose an hypocontractile detrusor, abdominal pressure efforts during voiding and obstruction (low voiding flow associated with a high bladder pressure). The reproducibility of pressure flow studies seems to be very good in the literature. Nomograms have been described to assess a possible obstruction, but some studies show no correlation between the severity of symptoms of bladder outlet obstruction and results on the main nomogram (nomogram of Blaivas). The measurement of the thickness of the bladder wall appears correctly correlated to the diagnosis of obstruction but measures vary significantly depending on the abdominal or vaginal ultrasonographic approach. CONCLUSION: In literature, only methods of measurement of maximum urinary flow rate and post-void residual volume have been extendedly studied.

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.

[Female overactive bladder syndrome and autonomic nervous system]. / Hyperactivité vésicale idiopathique de la femme et système nerveux autonome.

PURPOSE: To analyse the hypothesis of an autonomic nervous system dysfunction in the female's idiopathic overactive bladder syndrome, by a literature review. METHOD: A systematic literature review (Pubmed, Medline, Cochrane database) concerning women presenting with overactive bladder syndrome and cardiovascular explorations of the autonomic nervous system (heart rate variability and cardiovascular tests). Keywords used for search: overactive bladder syndrome, female urinary incontinence, urge incontinence, autonomic nervous system. RESULTS: Heart rate variability (HRV) analysis among women with overactive bladder syndrome and controls has shown a difference between both, with is a global decrease of the heart rate variability parameters, or a relative increase of the sympathetic tone in overactive bladder syndrome. The sympathetic cardiovascular tests were more frequently abnormal among women presenting with overactive bladder syndrome than controls. CONCLUSION: All these studies suggest a sympathetic dysfunction of the autonomic nervous system in female's overactive bladder syndrome, but methodologies are too variable and the studies population too small to establish a pathophysiological link.

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.

[Prospective evaluation of intrasphincteric injections of autologous muscular cells in patients with stress urinary incontinence following radical prostatectomy]. / Évaluation prospective du traitement de l'incontinence urinaire post-prostatectomie par injections intrasphinctériennes de cellules musculaires autologues.

PURPOSE: Cell therapy for urinary incontinence management has been experienced in animals with encouraging results, but studies in human beings are lacking. Our primary objective was to assess the safety of intrasphincteric injections of autologous muscular cells in patients with postprostatectomy incontinence (PPI). Secondary objectives focused on complications efficacy. METHODS: We conducted an open, prospective study in a single center on 12 patients presenting PPI. Patients underwent intrasphincteric injections of autologous muscular cells isolated from a biopsy of deltoid muscle. The primary endpoint was the Q(max) variation at the three month visit in order to assess potential bladder outlet obstruction. Secondary endpoints assessed side effects and efficacy parameters based on symptoms, quality of life score, voiding diary, pad-test, and urethral pressure profile at one, two, three, six and 12 months after injection. RESULTS: No immediate complication occurred and no significant variation was noted on Q(max). The only side effects possibly product-related were three cases of urinary tract infection treated by antibiotics. An acceptable safety and tolerability of the procedure whatever the injected dose of muscular cells was demonstrated. Results on efficacy after one year were heterogeneous, with 4/12 patients describing reduced urine leakage episodes, 1/12 patient presenting increased maximal closure pressure, and 8/12 patients showing improvement on pad-test. CONCLUSIONS: Cell therapy consisting of intrasphincteric injections of autologous muscular cells in patients with PPI was a feasible and safe procedure. The results point out that some subjects may positively respond to this procedure, but clinical efficacy remains to be confirmed.