[Outcomes of transcutaneous posterior tibial nerve stimulation for overactive bladder in diabetic patients]. / Résultats de la neurostimulation tibiale postérieure transcutanée pour hyperactivité vésicale chez les patients diabétiques.

OBJECTIVE: Treatment with transcutaneous posterior tibial neurostimulation (NTPT) has been shown to be effective in the treatment of overactive bladder (OAB), but its outcomes in diabetic patients have never been assessed. The aim of this study was to compare the efficacy of NTPT in diabetic OAB patients and in OAB patients without diabetes. METHODS: A single-center prospective study included all patients treated with NTPT for lower urinary tract storage symptoms between 2012 and 2016. The primary endpoint was symptoms improvement≥50% assessed using a Visual Analog Scale (VAS) two months after starting NTPT. Treatment consisted in a daily 20-minute NTPT single-session. The secondary endpoints were lower urinary tract symptoms reported by bladder diary, the Urinary Symptom Profile, the impact on mood and on daily activities. RESULTS: Seventy-one patients were included, 10 of whom were diabetic. The efficacy rate (EVA>50%) was not significantly different in the diabetic group (70% vs. 44.1%, P=0.17), like the mean EVA efficacy was similar in both groups (4/10 vs. 4/10, P=0.98). OAB USP sub-score diminished significantly in both groups at 2 months (-3 points in the diabetic group; -1.9 points in the non-diabetic group; P=0.03 and P<0.0001, respectively). There was no significant difference between the groups, except for the rate of patients who stopped treatment at 6 months, higher in diabetic patients (100% vs. 63.5%, P=0.04). CONCLUSION: The functional outcomes of NTPT appear to be similar in the treatment of OAB in diabetic patients and in non-diabetic patients. LEVEL OF EVIDENCE: 4.

Routine enema before urodynamics has no impact on the quality of abdominal pressure curves: Results of a prospective controlled study.

AIMS: The presence of stools in the rectum might affect the quality of the abdominal pressure curve during filling cystometry, but, to date, no study has evaluated the impact of bowel preparation before urodynamics. We evaluated the influence of a sodium phosphate enema before urodynamics on the quality of the abdominal pressure curve. METHODS: A prospective, controlled, single-blind study was conducted in a single center from May to June 2013. The patients were divided into 2 consecutive groups: patients seen in outpatient clinics during the first 6 weeks (group A) who underwent urodynamics without bowel preparation and patients seen in outpatient clinics during the second 6 weeks (group B) who had a prescription of sodium phosphate enema before urodynamics. The primary endpoint was the quality of the abdominal pressure curve evaluated independently by three physicians who were blinded to the study group. The following data were also collected: age, gender, the presence of a neurological disorder, complicated nature of urodynamics and bother related to preparation for it, assessed using a Likert scale (0 to 10), and the equipment used. A per protocol analysis and an intent-to-treat analysis were conducted. RESULTS: One hundred and thirty-nine patients were included: 54 in group A and 85 in group B. One-third of patients had neurological conditions. 14 patients in group B did not perform their scheduled enema. Thus, 68 patients performed an enema before urodynamics and 71 did not. There was no difference between groups A and B regarding the complicated nature of urodynamics (Likert scale: 3.12 vs. 3.18; P=0.91) or bother related to preparation for it (Likert scale: 3.46 vs. 2.97; P=0.43). In the per protocol analysis, the abdominal pressure curve was considered perfectly interpretable (PI) in 69% of patients who did not receive an enema before urodynamics and in 65% of patients who did (P=0.61). The between-group difference was not statistically significant in intent-to-treat analysis (P=0.99). In patients who did not receive an enema before urodynamics, the only factors statistically associated with better quality of abdominal pressure curves were age <60years (P=0.001) and the urodynamic equipment used (Dantec®>Laborie®; P=0.01). CONCLUSION: In this prospective study, routine enema before urodynamics did not improve the quality of the abdominal pressure curve and did not increase the complicated nature of urodynamics or the bother of preparation for it. LEVEL OF EVIDENCE: 3.

[Preliminary study: Lower urinary tract dysfunction and anorectal disorders in children with cerebral palsy]. / Étude préliminaire des troubles vésico-sphinctériens et anorectaux chez les enfants paralysés cérébraux.

GOAL: Describe lower urinary tract dysfunction and anorectal disorders to children with cerebral palsy (CP), indicating their impact on quality of life. MATERIALS: This was a prospective single-center study. A data collection was: type of PC, Gross Motor Function-Classification System (GMF-CS), mainstream education or not, Functional Independence Measure in children (MIF-kid), standardized vesicosphincteric symptoms and quality of life questionnaires (specific issue of impact sphincter dysfunction and generic scale Kidscreen-52). RESULTS: Between January and March 2013, 19 children aged 5-17 years were included, including 16 into mainstream schooling. Of the 19, 16 had bladder and sphincter disorders: 14 urinary incontinence, 3 nycturies, 6 dysuria, 12 urgenturies, no urinary infection. Of the 14 urinary incontinence, 13 were in school. Of the 16 children enrolled, 5 were daytime fecal incontinence and 2 nocturnal fecal incontinence. Functional scores (GMF-CS and MIF-kid) children urinary incontinence were lower than those of children urinary continents (P=0.04 and 0.0007). Ten children had an impact of these disorders on quality of life. All were enrolled, eight (80%) in the mainstream. CONCLUSION: The bladder and sphincter disorders were common in children with CP. They led to an impact on quality of life in more than half of the children studied, mostly educated in mainstream schools.

[Management of overactive bladder in women]. / Prise en charge de l'hyperactivité vésicale chez la femme.

Overactive bladder (OAB) is defined as urgency, with or without urge incontinence, usually with frequency and nocturia. OAB has been reported in 9 to 43% of female patients. It is usually idiopathic. The diagnosis is clinical but an initial work-up may be needed to exclude an underlying cause (bladder tumor, stone, cystitis, neurological disorder…) using urinary tract ultrasound, urine culture or cystoscopy. The initial assessment may also include a frequency-volume chart and urodynamics. Behavioral therapy is the first line treatment. In case of failure, antimuscarinics are recommended. Nowadays, three treatment options are available for OAB refractory to antimuscarinics: sacral neuromodulation, peripheral tibial nerve stimulation and intra-detrusor injections of botulinum toxin. Surgical procedures such as augmentation cystoplasty are very rarely required.

[The role of urinary markers in the assessment and follow-up of lower urinary tract disorders: a literature review]. / Place des biomarqueurs urinaires dans le diagnostic et le suivi des troubles du bas appareil urinaire: une revue de la littérature.

OBJECTIVES: To conduct a literature review on the role of urinary biomarkers in the initial assessment and follow-up of lower urinary tract symptoms. METHODS: A literature review was conducted in August 2014 using the Medline/Pubmed database limiting the search to work in English or French. RESULTS: Most studies were of level of evidence 2 or 3 (prospective cohort, controlled or not) and mainly about overactive bladder and bladder pain syndrome. Nerve Growth Factor (NGF) was the most studied and apparently the most promising in the evaluation of overactive bladder (OAB) and neurogenic detrusor overactivity (NDO). Urinary levels of ATP, prostaglandin E2 (PGE2), Brain-Derived Neurotrophic Factor (BDNF) and some cytokines were also significantly higher in most studies in patients with NDO or OAB. Epidermal Growth Factor (EGF), Heparin-Binding EGF (HBEGF) and Antiproliferative Factor (APF) were the most studied urinary markers in bladder pain syndrome, with a significant increase (EGF APF) or decrease (HBEGF) in cases of interstitial cystitis (compared to healthy controls). The urinary N-terminal-telopeptide (NTx) could be predictive of a failed mid-urethral sling. However, few studies reported the diagnostic values of the markers, their association with urodynamic parameters were rarely evaluated and the existence of a publication bias is likely. No randomized controlled study has so far compared the urinary markers to urodynamic evaluation. CONCLUSION: In the future, urinary markers could complete or replace urodynamic examination. However, to date, there is no high level of evidence study comparing these markers to urodynamics and their use can therefore not be recommended in daily practice.

[Definition of botulinum toxin failure in neurogenic detrusor overactivity: Preliminary results of the DETOX survey]. / Définition et prise en charge de l'échec d'une première injection de toxine botulique Botox ® 200 U pour hyperactivité détrusorienne neurogène: résultats de l'enquête DETOX.

OBJECTIVE: There is currently no guideline regarding the management of neurogenic detrusor overactivity (NDO) refractory to intra-detrusor botulinum toxin injections. The primary objective of the present study was to find a consensus definition of failure of botulinum toxin intra-detrusor injections for NDO. The secondary objective was to report current trends in the managment of NDO refractory to botulinum toxin. METHODS: A survey was created, based on data drawn from current literature, and sent via e-mail to all the experts form the Group for research in neurourology in french language (GENULF) and from the comittee of neurourology of the French urological association (AFU). The experts who did not answer to the first e-mail were contacted again twice. Main results from the survey are presented and expressed as numbers and proportions. RESULTS: Out of the 42 experts contacted, 21 responded to the survey. Nineteen participants considered that the definition of failure should be a combination of clinical and urodynamics criteria. Among the urodynamics criteria, the persistence of a maximum detrusor pressure>40 cm H2O was the most supported by the experts (18/21, 85%). According to the vast majority of participants (19/21, 90.5%), the impact of injections on urinary incontinence should be included in the definition of failure. Regarding the management, most experts considered that the first line treatment in case of failure of a first intra-detrusor injection of Botox(®) 200 U should be a repeat injection of Botox(®) at a higher dosage (300 U) (15/20, 75%), regardless of the presence or not of urodynamics risk factors of upper tract damage (16/20, 80%). CONCLUSION: This work has provided a first overview of the definition of failure of intra-detrusor injections of botulinum toxin in the management of NDO. For 90.5% of the experts involved, the definition of failure should be clinical and urodynamic and most participants (75%) considered that, in case of failure of a first injection of Botox(®) 200 U, repeat injection of Botox(®) 300 U should be the first line treatment.

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.

[Evidence of pudendal neuropathy in Proctalgia Fugax: perineal neurophysiological assessment in 55 patients]. / Proctalgies fugaces et neuropathie pudendale : étude neurophysiologique périnéale chez 55 patients.

OBJECTIVE: Proctalgia fugax (PF) is a very common condition especially in women. Causes and pathophysiological mechanisms of PF are unknown. Recently, a pudendal neuropathy was clinically suspected in women with PF. The goal of our study was to demonstrate, or not, such abnormalities by means electrophysiological testing. PATIENTS AND METHODS: Fifty-five patients with PF (45 female and 10 male, mean age 50.2 years) were evaluated. EMG testing with motor unit potential analysis of pelvic floor muscles (bulbocavernosus muscle and striated external anal sphincter), study of bulbocavernosus reflex and pudendal nerve terminal motor latencies (PNTML) were performed. RESULTS: EMG testing was altered in two males out of 10 (20%) and 29/45 females (64%). In women, denervation was found bilateral in 25/29 (86%). Sacral latency was delayed in eight out of 29 (bilateral in five cases, unilateral in three cases) and PNTML altered in 17 cases (13 bilateral alteration, four unilateral). A significant difference (P<0.002 Chi(2) test) was demonstrated between male and female concerning pelvic floor muscles denervation. CONCLUSION: Pelvic floor muscles denervation was a common feature in women suffering from PF, due to a stretch bilateral pudendal neuropathy. Distal lesions of the pudendal nerves, principally due to a stretch perineal neuropathy, can be imagined as a factor or co-factor of PF.

[Bladder deformations in neurogenic bladder secondary to cauda equina or conus medullaris lesion]. / Signes de lutte dans les vessies neurologiques des lésions de la queue de cheval et du cône terminal.

INTRODUCTION: The bladder deformations observed in the neurogenic bladders are frequent, particularly in the "upper motor neuron" bladder type (paraplegia, multiple sclerosis). We wanted to verify the predictive factors of such damage and particularly, if the urodynamic typology intervened in their genesis by using the model of cauda equina syndrome and conus medullaris lesions. PATIENTS AND METHODS: We have studied retrospectively the presence of cystographic bladder deformations at patients with neurogenic bladder due to cauda equina syndrome or conus medullaris lesion according to their urodynamic status: either overactive or acontractile detrusor. RESULTS: Of 68 patients, (mean age 47.2 years), 34 had an overactive and 34 an acontractile detrusor. The presence of bladder deformations was associated with an overactive detrusor (p=0.04). However, 50% of the patients with acontractile detrusor had bladder deformations, and those deformations were associated with male sex, and this excluding urologic obstruction. CONCLUSION: This study demonstrates the existence of bladder deformations in the hypoactive lower motor neuron neurogenic bladder type. If the bladder deformations seem more frequent in the overactive neurogenic bladder type, their specific and repeated search is also necessary during the follow-up of the lower motor neuron neurogenic bladder type.

Perineal neuromuscular fatigue.

AIM: The physiology of urinary continence during stress is complex and the role of passive and active mechanisms remains unclear. Coughing leads to a contraction of urethral rhabdomyosphincter and pelvic floor muscles leading to a positive urethro-vesical gradient and continence. Neuromuscular fatigue can involve all striated muscles, including rhabdomyosphincter, peri-urethral and pelvic floor muscles. This article reviews results of studies assessing perineal muscular fatigue in urinary incontinence. MATERIALS AND METHODS: A systematic review of the literature (Medline, Pascal and Embase) with use of the MESH keywords fatigue, stress, urinary incontinence, pelvic floor, urethra, urethral pressure, and muscle. RESULTS: Animal models have shown that the pelvic muscles (iliococcygeus and pubococcygeous) exhibit more neuromuscular fatigue than classical skeletal striated muscles (i.e. soleus muscle). Although the human external urethral sphincter is considered to be a highly fatigue-resistant muscle with its high proportion of slow muscle fibers, repeated coughing seems to lead to decreased urethral pressure in numerous women affected with stress urinary incontinence. In this case, "urethral fatigue" might be a possibility. CONCLUSIONS: Although few studies have focused on perineal muscular fatigue, such increased fatigue in pelvic floor muscles may play a role in the pathophysiologic features of stress urinary incontinence in women.

[Assessment of anorectal disorders with paraplegia]. / Evaluation à distance des troubles anorectaux chez les paraplégiques.

INTRODUCTION: Functional anorectal disorders in paraplegia are frequent; few studies evaluate the effect of these disorders on quality of life. OBJECTIVE: Assessment of the functional anorectal disorders in a homogeneous group of patients with total paraplegia in terms of quality of life. METHODS: During a global follow-up consultation, patients answered questions on a systematic questionnaire about anorectal disorders and a specific quality-of-life autoquestionnaire about functional digestive disorders: Functional Digestive Disorders Quality of Life (FDDQL) questionnaire; score 0 to 100 (100 corresponding to no effect on quality of life). RESULTS: Twenty-three patients with a mean age of 44.3 years who had been paraplegic for 10 years participated. Two had a colostomy because of bedsores. Fourteen underwent daily rectal examination, 10 with an evacuation aim; the time given to defecation was, on average, 36 minutes. One patient had clinical constipation. Twelve had had one or more episodes of incontinence. The mean global FDDQL score was 69.7. This score was not related to incontinence; only the "comfort" domain among the 8 domains was related to incontinence. DISCUSSION: Anorectal disorders are frequent in paraplegia; the duration and the methods of defecation represent a great worry to patients. More than half of the patients already had faecal incontinence; the effect of even occasional incontinence on quality of life is significant. Since the FDDQL scale is not specific to patients with paraplegia, its interest should be checked on a greater number of patients. For certain patients, it is important not to dismiss more complex surgical treatment methods.