Testicular resistive index determined by Doppler ultrasonography in men with spinal cord injury - a case series.

In this case series, the testicular resistive index was determined in men with spinal cord injury. In ten men participating in our fertility programme, the peak systolic and end-diastolic velocity of centripetal testicular arteries was measured in triplicates by Doppler ultrasonography to calculate the testicular resistive index. Furthermore, the right and left testicular volume was determined by ultrasonography, blood samples were obtained for hormonal evaluation, and sperm analysis was performed according to the WHO guidelines. The median testicular resistive index measured 0.69 and was significantly (P < 0.001) greater than the reported cut-off value of 0.6. The spermiograms were characterised by normal sperm count but decreased sperm motility and plasma membrane integrity. The median right and left testicular volume was significantly (P < 0.01) smaller compared to the volumes measured in able-bodied adult males without scrotal pathology and measured 8.4 ml and 7.2 ml respectively. There was a significant (P = 0.005) correlation (rs  = 0.81) between testicular resistive index and sperm concentration. However, no correlations were observed between testicular resistive index and other variables. The testicular resistive index in men with spinal cord injury was significantly greater than 0.6. Measuring the testicular resistive index may represent a useful additional parameter in the assessment of infertility in spinal cord-injured men.

Bladder stones in patients with spinal cord injury: a long-term study.

STUDY DESIGN: Retrospective follow-up study. OBJECTIVES: To assess the occurrence of bladder stones in patients with spinal cord injury (SCI). SETTING: Single SCI rehabilitation center in Switzerland. METHODS: We searched our database for SCI patients who had undergone surgery due to bladder stones between 2004 and 2012. In all patients retrieved, personal characteristics, bladder management, bladder stone occurrence and time to stone formation/recurrence were recorded. RESULTS: We identified 93 (3.3%) of 2825 patients with bladder stones, 24 women and 69 men, with a mean age 50 years (17-83) years. We observed bladder stones in patients with suprapubic catheter (SPC) in 11% (50/453), transurethral catheter (TC) in 6.6% (5/75), with intermittent catheterization (IC) in 2% (27/1315) and with reflex micturition (RM) in 1.1% (11/982), respectively. The mean time period to stone development was 95 months. The TC group had the shortest time interval (31 months), followed by the SPC group (59 months), individuals performing IC (116 months) and RM (211 months), respectively. Bladder stone recurrence rate was 23%. Recurrences were most frequent in the TC group (40%), followed by SPC (28%) and IC (22%), whereas no recurrences occurred in the RM group. Time to recurrence was shortest in the SPC group (14 months), followed by the IC (26 months) and the TC group (31 months), respectively. CONCLUSION: In SCI patients, bladder management has an important role in the development of bladder stones. Indwelling catheters (TC/SPC) are associated with the highest risk to develop bladder stones and therefore should be avoided if possible. If unavoidable, SPC are superior to TC.

Sacral rhizotomy: a salvage procedure in a patient with autonomic dysreflexia.

STUDY DESIGN: Case report. OBJECTIVES: To show the feasibility of sacral deafferentation as a salvage procedure to resolve life-threatening autonomic dysreflexia. SETTING: Paraplegic center in Switzerland. METHOD AND RESULTS: In a patient presenting with acute autonomic dysreflexia leading to cardiac arrest, sacral deafferentation could prevent further episodes of autonomic dysreflexia. CONCLUSION: In patients with spinal cord injury, autonomic dysreflexia can be triggered by the bladder even without detrusor overactivity. In these cases, sacral deafferentation may be the only salvage procedure to prevent further serious health problems. Thus, this procedure augments the armamentarium of urologists dealing with patients suffering from spinal cord lesions.

Cross-sectional study of the sperm quality in semen samples from spinal cord injured men after long-term cryopreservation.

The deterioration of semen quality occurs very early after spinal cord injury (SCI). Thus, routine cryopreservation of semen early after injury has been recommended. However, there is currently a lack of data concerning the effects of long-term cryopreservation on the quality of spermatozoa from SCI men. We have therefore investigated the quality of spermatozoa from SCI men before and after long-term cryopreservation. The semen cryobank of a SCI rehabilitation center was screened for samples with a storage duration of more than 3 years, to carry out a cross-sectional study regarding the sperm quality of semen samples from SCI men. Semen quality analysis was carried out according to the WHO-Guidelines. The quality of 28 semen samples from 16 SCI men was investigated prior to and a median 11 years (95% CI 7-13 years) after cryopreservation. Prior to cryopreservation, ejaculate volume (median = 1.7 mL, 95% CI 1-3 mL) and sperm concentration (median = 106 × 10(6) /mL, 95% CI 82-132 × 10(6) /mL) were within normal limits, but total sperm motility (median = 19%, 95% CI 13-22%) and viability (median = 27%, 95% CI 19-45%) were reduced. Cryopreservation resulted in a significant (p < 0.0001) decrease in total sperm motility (median = 2.5%, 95% CI 0-4%) and viability (median = 7%, 95% CI 6-13%). There were no significant (p = 0.75) differences between the semen parameters of samples collected early (up to 3 weeks) after SCI and those collected later. Complete SCI had a significantly (p < 0.0001) negative effect on the sperm viability of the fresh semen samples, and tetraplegia had a significantly (p < 0.035) negative effect on both pre-cryopreservation sperm viability and post-cryopreservation motility. The assisted ejaculation technique had no significant (p > 0.053) effect on semen quality. Long-term cryopreservation of semen from SCI men results in essentially immotile sperm with minimal viability. Thus, routine long-term cryobanking of semen harvested early after SCI cannot be recommended.

Interspike intervals of secondary muscle spindle and urinary bladder afferents in relation to the oscillation periods of sacral spinal oscillators for continence in man.

Two pairs of wire electrodes were used to record afferent and efferent single fibre extracellular action potentials (APs) from human nerve root filaments. The nerve fibres were identified according to the group to which they belong by comparing the afferent and efferent conduction velocity distribution histograms and identifying peaks and ranges of nerve fibre groups. Secondary muscle spindle afferents and alpha 2-motoneurones (FR) were identified by having the same peak group conduction velocity (calibration relation), which is 50 m/s at 36 degrees C. On the basis of AP wave form comparisons, the natural impulse patterns of five secondary muscle spindle afferents, two fusimotor motoneurones and two oscillatory firing alpha 2-motoneurones could be identified in the dorsal S4 root. The patterns of single endings of secondary spindle afferent fibres could be identified. The shortest interspike intervals of single endings of all secondary muscle spindle afferents had the same duration as the shortest interspike intervals of the two fusimotor fibres (80 ms) and equalled a half of the oscillation period of one repetitively firing alpha 2-motoneurone (6 Hz) probably innervating the external anal sphincter (three AP impulse train firing). In another more rostral dorsal root filament (probably S3 or S2) of the same human, the interspike intervals of six secondary spindle afferents were more variable. The values of peaks in the interspike interval distributions ranged from 60 to 102 ms. In the coccygeal root, the interspike interval duration ranged from 160 to 185 ms, directly contributing to the drive of the oscillatory firing alpha 2-motoneurone. The different agreement between the oscillation period and the interspike intervals of the spindle afferents in different segments indicate that the oscillatory firing CNS circuitry was localized within S3 to S5 segments of the conus medullaris for the drive of the anal sphincter. An alpha 2-motoneurone firing repeatedly with 1 to 2 AP impulse trains, innervating most likely the external urethral sphincter, fired at a frequency of 9.1 to 6.7 Hz, a similar frequency of the oscillation as the interspike intervals from two activated stretch receptors of the urinary bladder wall. The measurements of this brain-dead human indicates that in this case the neuronal circuitry driving the external anal sphincter was mainly confined to the sacral micturition and defecation centre, mainly located in the S3 to S5 segments.

[Clinical and urodynamic effects of oral propiverine therapy in neurogenic urinary incontinence. A multicenter study for optimizing dosage]. / Klinische und urodynamische Effekte einer oralen Propiverintherapie bei neurogener Harninkontinenz. Eine multizentrische Studie zur Dosisoptimierung.

The efficacy and tolerability of propiverine hydrochloride (in doses of 15, 30, 45 and 60 mg/day) were evaluated in the treatment of 66 patients suffering from neurogenic incontinence for 21 days in an open, randomized, multicentre, parallel-group trial. Evaluation of efficacy was based on changes in cystometry, flow measurements and micturition and that of safety on adverse reactions and blood chemistry. The bladder volume increased and bladder pressure decreased dose dependently; the ratio of the two increased by 0.6, 3.3, 3.8 and 8.1 ml/cm H2O after 15, 30, 45 and 60 mg/day respectively. Some 54% of patients had a decreased micturition frequency after 15 mg/day and about 80% after 30-60 mg/day. At the same time, 8, 35, 12 and 42% of patients had subjective anticholinergic symptoms after therapy with 15, 30, 45 and 60 mg/day, respectively. The results suggest that propiverine is a safe and effective drug for the treatment of neurogenic incontinence. A daily dose of 30 mg propiverine is recommended; individual adjustment of the maintenance dose to 15 or 45 mg/day may be necessary.

[Urethral condyloma in a patient with neurogenic bladder dysfunction: a therapeutic challenge]. / Urethrale Kondylome bei einem Patienten mit neurogener Blasenfunktionsstörung : Eine therapeutische Herausforderung.

Urethral condyloma is a therapeutic challenge. This article reports the case of a patient with spinal cord injury with the incidental finding of a massive spread of urethral condyloma. After removal of the condyloma with biopsy forceps neither recurrence of the condyloma nor a urethral stricture occurred. In patients where intermittent catheterization is performed, condyloma may be dispersed into the bladder, therefore, prompt endoscopic removal is crucial. As condyloma frequently recurs even after complete removal regular controls are mandatory.

[Squamous cell carcinoma of the bladder in a patient with HIV and paraplegia]. / Plattenepithelkarzinom der Harnblase bei einem Patienten mit HIV und Paraplegie.

In patients with spinal cord injury (SCI) the rate of squamous cell carcinomas (SCC) among bladder tumors is increased compared to the general population. An increased life expectancy is achieved by modern HIV treatment so that more AIDS-unrelated malignomas, e.g. bladder tumors, occur in these patients. Therefore, the risk for SCC in this group of patients is increased in patients with SCI and HIV but the combination of these two diseases is rare. We report the first case of SCC in a patient with SCI and HIV. Initial symptoms of bladder tumors in patients with SCI are often unspecific; therefore, in cases with new onset hematuria, recurrent urinary tract infections and changes in bladder function, cystoscopy and computed tomography (CT) scanning should be considered.

[A cylinder aneurysm of a penile prosthesis]. / Das Penisprothesenaneurysma.

Herniation of a penile prosthesis (cylinder aneurysm) is an extremely rare complication of penile prosthesis surgery. We report the first case of such an aneurysm in a patient with spinal cord injury. The treatment of choice is surgical revision with replacement of the faulty device. Filling of the implanted system with contrast media facilitates preoperative diagnostic workup.

'Neurogenic' urinary tract dysfunction: don't overlook the bowel!

STUDY DESIGN: Case report. OBJECTIVES: To demonstrate that massive constipation is a rare cause for bladder dysfunction. SETTING: Paraplegic centre in Switzerland. METHOD AND RESULTS: In two patients presenting with acute deterioration of bladder dysfunction, evaluation demonstrated compression of the urinary tract by massively distended colon due to excessive constipation. CONCLUSION: Colorectal dysfunction may intensify neurogenic urinary tract dysfunction simply by mechanical compression. Treatment of constipation can improve bladder function in these patients. With increasing time since spinal cord injury, the possibility of this finding should be taken into account in patients with newly diagnosed upper or lower urinary tract obstruction.

Perineal abscess formation as a complication of intermittent self-catheterization.

STUDY DESIGN: Case report. OBJECTIVES: To present a rare but severe complication of intermittent catheterization. SETTING: Paraplegic centre in Switzerland. METHOD AND RESULTS: A 52-year-old man presenting with fever and septicaemia was diagnosed with a perineal abscess due to a bulbar urethral lesion caused by acute false passage during intermittent catheterization. CONCLUSION: Especially in patients with a history of urethral strictures performing intermittent catheterization, the possibility of perineal abscess formation should be taken into account when treating such a patient with fever of unknown origin.

[Indications and results of transurethral 12 o'clock sphincterotomy in the therapy of neurogenic disorders of bladder emptying in transverse paralysis]. / Indikation und Ergebnisse der transurethralen 12-Uhr-Sphinkterotomie in der Therapie der neurogenen Blasenentleerungsstörungen bei Querschnittslähmung.

In 23 male patients with tetra- and paraplegia of a rehabilitation clinic for patients paralysed by a transverse lesion of the cord the transurethral 12-o'clock-sphincterotomy of the external vesical sphincter was performed on account of the neuromuscular dysfunction of the urinary bladder. In 78% of the patients the comparison of preoperative and postoperative clinical and urodynamic findings yields a positive result, i.e. decrease of the residual urine, reduction of the micturition pressure, regression of urinary stasis and reflux. The method is suited to influence favourably the life of these patients.

[Urologic treatment in phase I of the rehabilitation of paraplegics]. / Zur urologischen Behandlung in der Phase I der Rehabilitation Querschnittsgelähmter.

Transverse spinal cord lesions entail severe secondary pathological alterations to the urinary tract, reducing longevity and quality of life. It is, therefore, urgently recommended to take a coherent approach to such patients throughout the GDR and to use for urine voiding intermittent catheterisation right from Phase I of rehabilitation. A comparison between patients admitted for treatment in 1980, on the one hand, and those hospitalised 1985, on the other, revealed an opposite trend. Transfer of patients to Phase II of rehabilitation is thus rendered difficult, and the span of rehabilitation must be substantively extended.

[Development and course of functional urinary retention in paraplegic patients]. / Entwicklung und Verlauf funktioneller Harnstauungen beim Querschnittsgelähmten.

The urographic follow-up series of 453 patients of a paraplegic rehabilitation center are checked to obstructive uropathies. In 33 patients (7.3%) mostly asymptomatic obstructions were found. The onset of the urinary transport disorder is in 71% of the patients in the first year after the accident. Therefore, roentgenological and urodynamical investigations are necessary in the first years after the paralysis. The urological follow-up must be done for life as secondary morphological changes of the urinary tract are the cause of late obstructions. The prognosis of urinary transport disorders of the upper urinary tract is favourable in the case of timely and purposeful treatment. The development of a high-pressure system of the urinary bladder is the most important causal factor for qualified urodynamical diagnostic measures. Therefore, the therapeutic influence on the development of this high-pressure system is important in the prophylaxis and therapy of urinary obstruction.

[The status of intermittent self catheterization in the long-term management of paraplegic patients]. / Zum Stellenwert des intermittierenden Selbstkatheterismus in der Langzeitbetreuung querschnittsgelähmter Patienten.

The search for an optimal therapy of the disturbance of bladder function which required much extensive diagnostical measures may be long-term and much patience of both sides is necessary. A number of conservative measures is possible, but the most expensive therapy must not be the best treatment. We would be remember to a simple and safe method, but to its successful long-term application a good functioning care system is mandatory.

Detrusor-sphincteric dyssynergia in paraplegics compared with the synergia in a brain-dead human by using the single-fibre action potential recording method.

(1) Humans with spinal cord lesions often show detrusor-sphincteric dyssynergia of the urinary bladder which is reflected urodynamically in the detrusor pressure and a simultaneous increase in electromyographic pelvic floor activity. (2) The time-course of the increase in the secondary muscle spindle afferent activity, induced by the parasympathetic nervous system in muscle spindles contributing to continence, is very similar to that of detrusor pressure. The detrusor-sphincteric dyssynergia is therefore analysed by comparing the natural impulse patterns of secondary muscle spindle afferents (SP2) and sphincteric motoneurons in a brain-dead human with those in patients with spinal cord lesion. The parasympathetic nervous system was activated by painful bladder catheter pulling. (3) In a brain-dead human the sphincteric motoneurons subserving continence were inhibited at a time, when preganglionic parasympathetic efferents increased their activity for 10 s and an SP2 fibre increased its activity for several minutes. In a paraplegic with a strong bladder dysfunction, the SP2 fibre activity increased, due to parasympathetic activation, lasted for approx. 1 min, showed undulations and its amplitude was smaller than that measured in a brain-dead human. The sphincteric motoneurons were not inhibited. (4) In the brain-dead human, an SP2 fibre showed doublet firing with interspike intervals (IIs) of a duration between 10 and 14 ms for low level parasympathetic activation. For high level parasympathetic activation this single parent spindle afferent fibre showed multi-ending regular firing of up to 6 endings with IIs of a duration of predominantly 15 to 25 ms. In one paraplegic with a strong bladder dysfunction the doublet firing was less regular, even though two II peaks at 10.2 and 11.2 ms occurred in a II distribution similar to the brain-dead human. The multi-ending regular firing was replaced by a repeated burst firing. In a second paraplegic with strong detrusor-sphincteric dyssynergia the burst firing consisted of up to 6 impulses with increasing IIs and a first II of approx. 0.2 ms (transmission frequency 5000 Hz). In a third paraplegic with a lesser dysfunction of the bladder a highly activated SP2 fibre showed an activity pattern intermediate to those of multi-ending regular firing and burst firing. (5) The time constant for the activity decrease of a spindle afferent fibre following parasympathetic activation was to 31 s in a paraplegic and approx. 40 s in a brain-dead human. It is concluded that the muscle spindles are unchanged following spinal cord lesion.(ABSTRACT TRUNCATED AT 400 WORDS)