[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.