[Perineal electrical stimulation and rehabilitation in urinary incontinence and other symptoms of non-neurologic origin]. / Electrostimulation et rééducation périnéale de l'incontinence urinaire et des troubles mictionnels non neurologiques.

A literature survey of 106 articles shows that standard electrostimulation is an effective treatment of urinary incontinence and urinary disorders with bladder instability. Bladder inhibition is obtained by applying an alternating current at a frequency of between 5 and 25Hz and with a pulse width of between 0.2 and 0.5ms. In 19 articles (including three randomized, placebo-controlled studies), good results were achieved in 60 to 90% of cases, depending on the exact method (i.e. chronic or acute stimulation). Standard electrostimulation is also efficient in stress urinary incontinence. Urethral closure is obtained by applying a 50Hz alternating current with, again, a pulse width of between 0.2 and 0.5ms. In 21 articles (including two randomized, placebo-controlled studies), good results were achieved in 47.5 to 77% of cases. Treatments combining perineal rehabilitation (behavioural education, muscle improvement and biofeed-back) and electrostimulation are reported by 10 authors, with good results in 70 to 80% of cases after 10 to 12 sessions. According to 14 studies, neuromodulation is also an efficient treatment for complex urinary disorders, urgency, pollakiuria and dysuria. The recommended stimulation parameters are a frequency of 10 to 15Hz and a pulse width of 210ms. Good results were found in 34 to 94% of cases (with between 60 and 75% in an international, multicenter study). The overall results different from one study to another because of the need to harmonize stimulation parameters, choice of the study population and treatment follow-up with self-training programs and therapeutic education.

[Neuropathy with non-alcoholic thiamine deficiency: two cases of bladder disorders]. / Neuropathies par carence en thiamine sans intoxication alcoolique: deux cas de troubles vésicosphinctériens.

INTRODUCTION: Neuropathy with non-alcoholic thiamine deficiency is reported in the literature, but bladder disorders are rarely detailed. CASE REPORTS: We report two cases of bladder disorders in neuropathy with thiamine deficiency. One patient presented with a flaccid bladder and impaired sensation; the postvoid residual volume was raised. The other patient had reduced bladder capacity, with detrusor hyperreflexia and detrusor-sphincter dyssynergia. In both cases, the bladder disorders disappeared with thiamine supplementation. CONCLUSION: Bladder symptoms may be heterogeneous in nonalcoholic neuropathy. The prognosis is good after vitamin supplementation.

[Spontaneous muscular haematomas in hemiplegic patients receiving anticoagulation therapy]. / Hématomes musculaires spontanés chez les patients hémiplégiques sous traitement anticoagulant.

INTRODUCTION: Muscular hematomas are frequently reported as a complication of anticoagulation therapy. METHODS: We report six cases of spontaneous muscular hematomas occurring in hemiplegic patients receiving anticoagulation therapy using heparin, low-molecular-weight heparin or fluindione. Anticoagulation therapy was given in prophylactic doses to two patients to prevent deep vein thrombosis and in therapeutic doses to four patients with deep vein thrombosis, pulmonary embolism or cardiac arrhythmia. Two patients experienced episodes of bleeding when heparin and fluindione were temporarily associated. RESULT: Contrary to previous reports, the more frequent site of bleeding was not the ilio-psoas muscle (only 2 patients); hematomas were also observed in hip adductors and gluteus muscles. The most striking finding was the constant location of the hematoma on the hemiplegic side. CONCLUSION: Location on the hemiplegic side can lead to underestimating the frequency of neurologic compression by the hematoma; the diagnosis can nevertheless be established by electromyography. Local signs may not be present, but general signs of hypovolemia and anemia are more frequent. Ultrasound may be the first line investigation but in our experience, the results can be misleading and computed tomography (CT) or MRI are often required to confirm the diagnosis.

[Pyomyositis in an immunocompetent adult: unusual complication of rhabdomyolysis]. / Pyomyosite chez une patiente non immunodéprimée: complication inhabituelle d'une rhabdomyolyse.

INTRODUCTION: Non-tropical pyomyositis is a commonly reported infection in immunodeficient patients' muscle but is rare without immunodeficiency. CASE DESCRIPTION: We report the case of a 40-year-old woman admitted in the physical medicine and rehabilitation department for a motor and sensory loss of the lower limb; this disorder appeared after rhabdomyolysis due to prolonged lying position (suicide attempt). The initial diagnosis of sciatic nerve compression was not consistent with motor loss of adductor muscles. Clinical examination revealed soft tissue swelling in the proximal part of her lower limb. CT scan displayed pyomyositis of the thigh (hip adductors and gluteus medius), which was successfully treated by surgical incision and drainage in combination with antibiotherapy. CONCLUSION: Non-tropical pyomyositis is rarely described without immunodeficiency but this diagnosis should be borne in mind when previous muscle trauma is associated to leukocytosis. Computed tomography and MRI are the tests of choice to confirm the diagnosis of pyomyositis and to differentiate it from other entities.

[The shoulder-hand syndrome after stroke: clinical factors of severity and value of prognostic score of Perrigot]. / Algoneurodystrophie du membre supérieur de l'hémiplégique : facteurs cliniques de gravité et intérêt du score pronostique de Perrigot.

PURPOSE: The purposes of this study were to evaluate the prognostical factors of reflex sympathetic dystrophy in stroke patients in attempt to improve the Perrigot prognostical score. MATERIAL AND METHOD: This prospective study included 28 stroke patients with reflex sympathetic dystrophy. An initial clinical assessment including Perrigot score was made at the time of admission (before the end of the first month) and a second evaluation of reflex sympathetic dystrophy at the end of the third month. Patients were assessed using Motricity Index, Ashworth scale, de Bats grading (for glenohumeral alignment), Labrousse criteria (for reflex sympathetic dystrophy severity), and MADRS depression scale. Sensory deficit and unilateral neglect were noted. RESULTS: The length of stay in acute ward was 16 days. The Perrigot score was correlated with the reflex sympathetic dystrophy severity (r = 0.7, p < 0.0001). It predicted the result of therapy. A significant correlation was found between reflex sympathetic dystrophy severity and motor deficit (r = -0.591, p = 0.0007) and spasticity (p < 0.05). No relation was found with stroke side, unilateral neglect, depression or shoulder subluxation. It wasn't possible to improve the Perrigot prognostical score. CONCLUSION: Perrigot score predict reflex sympathetic dystrophy severity and the result of therapy. The shoulder subluxation which is not included in this score appears to be not predictive. Shoulder subluxation is simply a marker of a severe paresis.

[Suprapubic reflex. Electrophysiological study in normal patients]. / Le réflexe pubo-caverneux. Démonstration électrophysiologique.

INTRODUCTION: In spinal cord injuries patients, tapping the suprapubic aera is a strong stimulus to ellicit detrusor contraction and can be used in the management of neurogenic bladder. This stimulation also determines a perineal muscles contraction. This striated response was mentionned in animal studies but never specifically analysed in men especially in normal subjects. AIMS OF THE STUDY: Our objective was to describe pelvic floor responses with measurement of reflex latency following suprapubic mechanical stimulation. METHODS: 21 patients without neurological disease were studied. They were 14 women and 7 men. Mean age was 51 (SD=14,2). Motor responses were recorded with a needle electrode inserted in the left bulbocavernosus muscle. Stimulation was delivered with an electromechanical hammer, tapping directly on the suprapubic aera. RESULTS: A polyphasic muscular response was always and easily elicited in all patients. Mean latency was 67,5 ms. (SD = 14,7). The reproducibility between the first and second mechanical responses was good with no statistical difference (r=0,966; p=0,0001). DISCUSSION: Our study clearly demonstrates a suprapubic bulbocavernosus reflex (SBR). Many arguments can be retained for a polysynaptic reflex (polyphasic response, habituation and short latency of the reflex, mean latency in the habitual values of R2 responses following electrical stimulation of the dorsal nerve of the penis). We hypothetize that: the true stimulus is the stimulation of the bladder wall tenso-receptors; integration level of the SBR is the sacral segments and the efferent limb the pudendal nerve; afferent pathways could be vehicled by pelvic nerve fibers. CONCLUSION: Competition between a preponderant (or exaggerated) SBR and a bladder contraction following suprapubic tapping, may constitute a real functional outlet obstruction giving incomplete or complete retention in some suprasacral bladders. In normal subjects, SBR can be considered as a continence reflex with increase of perineal tone following the stimulation of the bladder wall tenso-receptors during stress.

Long-term results of sacral nerve stimulation (S3) for the treatment of neurogenic refractory urge incontinence related to detrusor hyperreflexia.

PURPOSE: We assess clinical and urodynamic results of sacral nerve stimulation for patients with neurogenic (spinal cord diseases) urge incontinence and detrusor hyperreflexia resistant to parasympatholytic drugs. MATERIALS AND METHODS: Since 1992, 9 women with a mean age of 42.6 years (range 26 to 53) were treated for refractory neurogenic urge incontinence with sacral nerve stimulation. Neurological spinal diseases included viral and vascular myelitis in 1 patient each, multiple sclerosis in 5 and traumatic spinal cord injury in 2. Mean time since neurological diagnosis was 12 years. All patients had incontinence with chronic pad use related to detrusor hyperreflexia. Intermittent self-catheterization for external detrusor-sphincter dyssynergia was used by 5 patients. Social life was impaired and these patients were candidates for bladder augmentation. A sacral (S3) lead was surgically implanted and connected to a subcutaneous neurostimulator after a positive test stimulation trial. RESULTS: Mean followup was 43.6 months (range 7 to 72). All patients had clinically significant improvement of incontinence, and 5 were completely dry. Average number of voids per day decreased from 16.1 to 8.2. Urodynamic parameters at 6 months after implant improved significantly from baseline, including maximum bladder capacity from 244 to 377 ml. and volume at first uninhibited contraction from 214 to 340 ml. Maximum detrusor pressure at first uninhibited contraction increased in 3, stabilized in 2 and decreased in 4 patients. Urodynamic results returned to baseline when stimulation was inactivated. All patients subjectively reported improved visual analog scale results by at least 75% at last followup. CONCLUSIONS: Sacral nerve stimulation can be used as a reversible treatment option for refractory urge incontinence related to detrusor hyperreflexia in select patients with spinal lesions.

Urethral pressure response to cough and voluntary perineal contraction in men without previous pelvic surgery.

The aim of this study was to analyze the urethral pressure responses to cough in men to better characterize the neurogenic mechanisms of male urethral function. A prospective study was carried out on 41 men referred for urodynamic assessment. Urethral pressure profiles at rest and during coughing, and urethral pressure response to voluntary perineal contraction were recorded and analyzed in relation to the neurological status of the patients. Voluntary perineal contraction resulted in a urethral pressure increase (delta pU) of approximately 150 cm H2O in neurologically normal patients. Delta pU could be reduced to any degree in patients with either central or peripheral neurological lesions. Urethral pressure response to cough could be easily classified into two main patterns. Pattern I was characterized by a marked increase in urethral closure pressure during the cough (ratio of urethral to rectal pressure increase: 248 +/- 106%), occurring at the distal part of the posterior urethra. All the neurologically normal patients and the majority of those with upper motoneuron lesions had a pattern I response. Pattern II was defined by the absence of any significant increase in urethral closure pressure at any site of the posterior urethra and was observed in 80% of the patients with signs of lower motoneuron lesions. The pattern of the response to cough was significantly related to the neurological status of the patients (P < 0.001). It was dissociated from the response to voluntary contraction, as would be expected for a reflex versus a voluntary response in neurological patients.

Is there a place for pudendal nerve maximal electrical stimulation for the treatment of detrusor hyperreflexia in spinal cord injury patients?

The aim of the study is to determine whether pudendal nerve maximal electrical stimulation (MES) could represent an alternative treatment for detrusor hyperreflexia in spinal cord injury (SCI) patients. Six suprasacral SCI patients participated in the study. The treatment consisted of daily stimulation periods of 20 min, repeated five times a week, during 4 weeks, with continuous electrical stimulation of the penis or of the clitoris via bipolar surface electrodes (rectangular stimuli of 0.5 ms pulse duration, 5 Hz frequency), with the maximum tolerable stimulation strength (under the level of pain). In two patients, additional stimulation was administrated by means of an anal plug during the last 2 weeks. The stimulus strengths ranged from 35 to 99 mA (mean 54 mA). One patient stopped MES after 2 weeks. At the end of the treatment, neither the cystometric bladder capacities (153 ml vs 157 ml) nor the micturition charts had significantly improved for the five remaining patients. Only two patients experienced non lasting improvement of nocturia at some time of the treatment. In conclusion, we were not able to demonstrate the efficacy of MES in inhibiting detrusor hyperreflexia in SCI patients. To reach therapeutic effects, other parameters may be needed, such as higher stimulation strengths (currents above or equal to 99 mA) or other currents (such as interferential therapy). Chronic stimulation with external or implanted electrodes using lower currents may represent an alternative.

Urinary disturbances in striatonigral degeneration and Parkinson's disease: clinical and urodynamic aspects.

Although urinary disturbances are more frequent in multiple system atrophy (MSA) than in Parkinson's disease (PD), the striatonigral degeneration (SND) type of MSA is difficult to distinguish from PD, especially when the latter is associated with orthostatic hypotension or urinary symptoms. The pattern of urinary symptoms and urodynamic dysfunction was analyzed in 15 SND and 35 PD patients with urinary complaints. In SND, dysuria with or without chronic retention, frequently associated with a hypoactive detrusor and low urethral pressure, permitted early and reliable diagnosis. In PD, urgency to void, with or without difficulty voiding, but without chronic retention, associated with detrusor hyperreflexia and normal urethral sphincter function, predominated. In clinical practice, the study of urinary symptoms and bladder function may help to distinguish SND from PD in patients with urinary disturbances.

Short-term effect of pudendal nerve electrical stimulation on detrusor hyperreflexia in spinal cord injury patients: importance of current strength.

Twenty patients with chronic suprasacral spinal cord injury presenting with detrusor hyperreflexia were examined. In a preliminary study in ten patients we investigated the reproducibility of bladder capacity through the repetition of three cystometries. The effect of electrical stimulation (ES) on detrusor hyperreflexia was then investigated in ten patients during three consecutive cystometries, the first one without ES (baseline) and the other two with continuous ES of the dorsal penile or clitoris nerve via surface electrodes. Parameters of stimulation were 5 Hz frequency, 0.50 msec pulse duration, and stimulation strength of 1 and 2 times the bulbocavernosus reflex threshold. No significant differences in bladder capacity were found between the three consecutive cystometries without ES (respectively 97.0 ml, 101.5 ml and 105.6 ml). A current at the bulbocavernosus threshold (mean 24.4 mA) failed to induce a significant increase in bladder capacity compared to baseline (173.0 ml vs 155.5 ml, P = 0.17) whereas a current of twice the bulbocavernosus threshold (mean 48.9 mA) was highly significant (318.5 ml vs 155.5 ml, P < 0.007). ES of twice the threshold resulted in perineal contraction in all of the patients, the threshold ES never did. Our results emphasise the decisive roles of perineal contraction and of current strength for achieving short-term bladder inhibition in spinal cord injury patients. The carry-over effect may also be dependent on the current strength. If so, maximal pudendal ES could represent an alternative procedure in the treatment of detrusor hyperreflexia in these patients.

Effect of intravenous alfuzosin on urethral pressure in patients with neurogenic bladder dysfunction. DORALI Study Group.

In order to assess the ability of a single intravenous (i.v.) injection of alfuzosin, a selective alpha-1 blocker, in reducing high urethral tone in patients with symptomatic neurogenic bladder dysfunction (NBD), 163 patients (mean maximal urethral pressure [MUP] 108 +/- 46 cm H2O) were enrolled in a double-blind, placebo-controlled, parallel-group trial and were randomly allocated to receive 0.5 mg (n = 45), 1 mg (n = 41), 2 mg (n = 39) alfuzosin or placebo (n = 38). The decrease in MUP was dose-dependent and statistically significant (P < or = 0.05) for 1 and 2 mg alfuzosin (respectively, 43 +/- 28 cm H2O and 46 +/- 27 cm H2O decreases vs. baseline) in comparison with placebo (23 +/- 30 cm H2O). The 2 mg dose level was the most effective leading to a > or = 30 or 50% decrease in MUP in, respectively, 69 and 44% of patients. The safety of all three alfuzosin dose levels was satisfactory and comparable to placebo. I.v. alfuzosin induces, in a dose-related manner, a clinically significant decrease in urethral pressure in patients with NBD and high urethral tone, and may be safely used as a pharmacological test as part of an urodynamic investigation.

Effects of metoclopramide on the urethral pressure profile of healthy dogs.

PURPOSE: The purpose of the present work was to study the effect of metoclopramide on urethral pressure since urethral relaxation is an important factor in vesical voiding. MATERIALS AND METHODS: Urethral pressure was measured in 6 dogs, anesthetized with propofol before and 1, 5 and 10 minutes after the administration of metoclopramide (0.5 mg/kg.) or placebo. RESULTS: A single injection of metoclopramide induced a large decrease in maximal urethral closure pressure (53 to 90%; mean 71%, p < 0.001--Anova). The decrease with placebo, 5 to 44% (mean 26%), was not significant (Anova test: p = 0.06). CONCLUSION: It is argued that a central dopaminergic action most probably accounts for this effect of metoclopramide on urethral pressure.

[Neurogenic bladder, 20 years later]. / Vessie neurologique, 20 ans après.

The therapeutic armamentarium--physical therapy, drugs, surgery--developed over the last 20 years now gives us the means of providing curative care to nearly all patients with manifestations of neuropathic bladder, meaning that the clinical examination and complementary tests must be conducted under strictly controlled conditions to identify the underlying mechanism. The examination of the perineum almost always reveals a defect when the origin is neurological but is often normal when gynaecologic or urologic factors are involved. Motor command, tonus, reflexes and sensitivity should all be carefully explored to distinguish between central and peripheral causes. Much progress has been made in complementary examinations. For example, nearly 100% of the neurological aetiologies can be identified with precision. Tests include electromyography of the perineum, measurement of the latency of the bulbocavernous reflex and that of the distal part of the internal pudental nerve. Complementary tests evaluating bladder and sphincter function include urine sediment with cytology, intravenous pyelography and echography of the urinary tract. Pressure measurements with cystomanometry, sphincterometry and flowmetry add further precisions. Whether the underlying mechanism of bladder dysfunction is purely neurological as is the case in many young patients with multiple sclerosis, spina bifida or caudia equina syndrome, results from several causes as in patients with Parkinson's disease and enlargement of the prostate, or is among the increasing number of post-radiation sequellae, the essential step is careful clinical examination and detailed interpretation of complementary examinations. Thus the wide range of techniques now available for the management of the neuropathic bladder can be adapted to each individual case according to the pathological processes causing the clinical manifestations.

[Prevalence of anal incontinence in adults]. / Etude de la prévalence de l'incontinence anale chez l'adulte.

Inquiries were conducted to determine the prevalence of anal incontinence in a) the general population over 45 by a gallup poll studying 1,100 persons (A); b) 3,914 patients seen by their general practitioner or their gastroenterologist during the same week (B); c) 500 patients consulting for urinary stress incontinence (C1); d) 1,136 neurological patients suffering from micturation disorders (C2); and e) 10,157 elderly persons living in retirement homes or in hospital (D). In the general community (A), the prevalence of anal incontinence, including gas and stool incontinence, was 11 percent, the prevalence of fecal incontinence, 6 percent, the prevalence of daily or weekly fecal incontinence, 2 percent; prevalences were respectively 15.5 percent, 7.9 percent, and 3.2 percent in group B, and 27 percent, 9 percent and 3.8 percent in group C1. The prevalence of fecal incontinence was 18 percent in group C2 and 33 percent in group D. Prevalence did not depend on age in group A and C1, but was twofold higher in group C1 than in group A. The prevalence increased with age in groups B and D.

[Perineal neuralgia and Alcock's canal syndrome]. / Névralgies périnéales et syndrome du canal d'Alcock.

Perineal neuralgia is characterised clinically by pain (burning type of perineal pain) exacerbated in the sitting position. It is secondary to impairment of the internal pudendal nerve in its musculo-osteo-aponeurotic tunnel composed by the ischium and the obturator internus muscle (ischiorectal fossa or pudendal canal). As in any nerve tunnel syndrome, pre-existing neuropathy constitutes a predisposing factor and should therefore be identified. The diagnosis of pudendal tunnel syndrome is confirmed by perineal electrophysiological investigations (detection of neurogenic muscles of the perineal floor, increased sacral latency). Treatment consists of infiltration, possible repeated, of the pudendal tunnel with a sustained-release corticosteroid under CT guidance.