[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.

[Notice of expert for modality and prescriptions limits of local estrogenotherapy for urinairy inconfinence in women]. / Avis d'experts sur les modalités et limites de prescription des estrogènes locaux dans l'incontinence urinaire chez la femme.

OBJECTIVE: To develop a consensus of experts on the use of local estrogens in female urinary incontinence. MATERIAL AND METHOD: Following a formalized consensus method (DELPHI), a questionnaire was produced and sent to a first round and then to a second round of experts. The questionnaire consisted of proposals for recommendations for the use of local estrogens in the context of female urinary incontinence. The Survey Monkey® survey software allowed the questionnaire to be distributed and the answers obtained to be analyzed. RESULTS: Eight experts responded to the first round questionnaire. Seven formulations were deleted, 3 amended and 4 added to the first round questionnaire following expert advice. Twenty-six experts replied to the second round questionnaire, 24 of which were complete. Ten of the 21 proposals were approved at more than 80%, including five with strong agreement regarding the recognized benefit of local estrogens in urinary incontinence due to overactive bladder, the absence of data from the literature to demonstrate over-risk of hormone-dependent cancer under local estrogens and the need for follow-up of patients under this treatment. Six proposals were not the subject of a consensus and concerned the prescription modalities (maximum duration, effective minimum dose, prescription before surgery for incontinence). CONCLUSION: Although local estrogens did not have regulatory approval in urinary incontinence, more than 80% of these experts recognized their benefit in the management of urinary incontinence in women with vulvo-vaginal atrophy, particularly in the case of urinary urge incontinence. LEVEL OF PROOF: 4.

[Antibioprophylaxy and urological management of women with spinal cord injury during pregnancy]. / Intérêt de l'antibioprophylaxie et manifestations urologiques des femmes blessées médullaires au cours de la grossesse.

OBJECTIVE: More and more women with spinal cord injury (SCI) can have a pregnancy. Few data have been published on these pregnancies and their urological impact. We report a series of these cases illustrating the urological experience of specialized centers. METHODS: This is a retrospective study that identified pregnancies in women with SCI followed-up between 2000 and 2014. Data covering all urological and obstetric events during pregnancies, before and after implementation of weekly oral cyclic antibiotics (WOCA) program, were collected from medical records. RESULTS: Fifteen women with SCI who gave birth to 20 children were included. Three of them were quadriplegics and 12 were paraplegics. All of them performed themselves intermittent catheterization: 11 by urethral way and 4 by high way because carrying a continent cystostomy. Mean follow-up period before pregnancy was 14.6 years [3-27 years IC 95%] and the mean follow-up for the study was 8.5 months [6.5-9 IC 95%]. We observed a reduction of symptomatic urinary tract infections after WOCA onset (13/13 before vs. 0/7 after, P=0.001), a reduction of recurrent urinary infections (6/13 vs. 0/7, P=0.03), a reduction of threats to premature births (8/13 vs. 0/7, P=0.001). Multi-resistant bacteria appeared to increase (0/13 vs. 3/7, P=0.01). We also observed a trend to significant reduction of premature births number (4/13 vs. 0/13, P=0.1) and that of low birth weight (3/13 versus 0/7, P=0.1). The overall neonatal survival rate was 100%. CONCLUSION: Our study before/after introduction of a weekly oral cycle antibiotic prophylaxis during pregnancy for women with spinal cord injury showed a significant reduction in symptomatic urinary tract infections and a tendency to improve pregnancy outcomes. LEVEL OF EVIDENCE: 4.

Clinical signs and radiographic evidence of esophageal perforation after tetraplegia.

A diagnosis of esophageal perforation at some time after cervical spine surgery is difficult to establish since there exists no clinical picture specific to tetraplegic patients. We carried out a detailed retrospective study of revelatory clinical manifestations and conventional radiographic data in a series of 16 patients hospitalized at Hôpital Henry-Gabrielle (Lyon, France) for rehabilitation purposes between 1983 and 2010 and who presented this complication. The most frequent clinical picture associates cervical pain, fever and dysphagia. Simple front and side X-rays of the cervical spine led in 77% of the cases to a diagnosis of esophageal perforation. The most prevalent radiographic signs of the latter consist in osteosynthesis hardware or instrumentation failure, prevertebral free air next to the cervical esophagus and enlarged prevertebral space. Visualized esophageal X-rays, also known as series, highlight parenchymal opacity next to the posterior wall of the esophagus. A diagnosis of esophageal perforation needs to be carried out in order to facilitate suitable treatment and avoid the compromising of vital functions.

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.