Urethral pressure profile during ejaculation in men with spinal cord injury.

Ejaculation is often impaired in men with spinal cord injury (SCI). The aim of this prospective study was to assess sequence of sphincteric events and ejaculation dyssynergia during penile vibratory stimulation (PVS) in SCI men. Simultaneous recordings of bladder, bladder neck, prostate and external urethral sphincter pressures were performed using a microtip catheter with 5 pressure transducers. Between 2017 and 2019, ten men participated in the study for a total of 17 procedures. Antegrade ejaculation was found in three men with upper motor neuron (UMN) lesion. Ejaculation was preceded by a progressive increase in all urethral pressures, reaching sustained (plateau) or intermittent peaks above 220 cm H20. Antegrade ejaculation occurred after intermittent decreases in pressure at the external urethral sphincter level down to 100 cm H20, while the pressure at the bladder neck remained high (up to or above 220 cm H20). PVS was ineffective in eliciting ejaculation in seven men. In the five patients with UMN lesions, PVS elicited an increase in the external urethral sphincter pressure (mean 51 cm H20), while there was no pressure change in the two patients with lower motor neuron lesions. Due to lack of enough retrograde retrieval attempts, the hypothesis of ejaculatory dyssynergia could not be verified.

Wearable powered exoskeletons for gait training in tetraplegia: a systematic review on feasibility, safety and potential health benefits.

BACKGROUND: Recent developments in wearable powered exoskeletons (WPE) allow gait training (GT) for patients after spinal cord injury (SCI). Two recent meta-analyses on GT using WPE showed promising results for paraplegic patients (PP). To this date, there is no review focusing on tetraplegic patients (TP). OBJECTIVES: The main objective of this review was to assess feasibility and safety of GT using WPE in patients after tetraplegia. METHOD: This systematic review was performed according to PRISMA-S guidelines. Two independent reviewers searched several databases for studies on GT using WPE for TP. Primary outcomes concerned the number, type and severity of reported adverse events (AE). Secondary outcomes examined potential additional health benefits (AHB). RESULTS: Forty-one studies (6 randomized trials, 24 cohorts and 11 cases series) were selected, including 166 TP, 26 with complete lesions (AIS A) and 71 with level of injury above C6. Minor AE were reported in 17 TP, concerning cutaneous, cardiovascular or musculoskeletal systems. Occurrence of AE is significantly higher in a PP population compared to TP (p value = 0.001). Only one major AE concerned a TP. Studies of low level of evidence suggest that GT using WPE could lead to improvements in walking parameters, cardiovascular efficiency and to a reduction of spasticity. DISCUSSION AND CONCLUSION: GT using WPE is a feasible and safe intervention for TP. To minimize occurrence of AE, a good patient selection and preparation is proposed. Future clinical trials should be performed to confirm current trends in terms of efficacy and potential AHB.

Evaluation of safety and performance of the self balancing walking system Atalante in patients with complete motor spinal cord injury.

STUDY DESIGN: Prospective, open label, observational. OBJECTIVES: To present results of the first clinical study on a newly developed robotic exoskeleton (Atalante®, Wandercraft, Paris, France) that enables individuals with spinal cord injury (SCI) to perform ambulatory functions without technical aids. SETTING: Two sites specialized in SCI rehabilitation, France. METHODS: Inclusion criteria were presence of chronic complete SCI (AIS A) ranging from T5 to T12. The study protocol included 12 one-hour training sessions during 3 weeks. Patients walked on floor with robotic assistance and wore a harness connected to a mobile suspension system (without weight-bearing) to prevent from falling. Main outcome was the ability to walk 10 meters unassisted, secondary outcomes were assessment of other ambulatory functions, bladder and bowel functions, pain and spasticity. RESULTS: Twelve patients were enrolled, and 11 completed the protocol, mean age 33,9 years. Six patients had T6 levels of lesion or above. Seven patients passed the 10mWT at the 12th session unassisted (mean walking speed 0.13 m/s) while four required some human help. All patients succeeded at the other ambulatory tests (stand-up, sit-down, balance, turn). There were no significant change for bladder (Qualiveen) or bowel (NBD) functions, neuropathic pain (NPSI, NPRS), yet five patients reported a subjective improvement of their bowel function. Impact on spasticity was variable depending on the muscle examined (Ashworth). Ischial skin erosion was seen in one patient that needed local dressing. CONCLUSION: The Atalante system is safe and enables to perform ambulatory functions in patients with complete SCI.

The sacral exam-what is needed to best care for our patients?

Sacral reflexes are important to allow the SCI practitioner to gain information about the state of the sacral spinal cord segments. The presence of the bulbocavernosus and/or the anal wink reflex indicate an intact spinal reflex arc and reflex conal autonomic function (as part of the upper motor neuron syndrome); their absence defines a lower motor neuron syndrome. The assessment of sacral reflexes helps predict the type of bladder, bowel and sexual functions and the related therapeutic interventions. We suggest adding the sacral component of the International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) to the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) examination so there can be a detailed description of these important functions. As an alternative, the performance of sacral reflexes should be routinely required as part of the neurologic examination after SCI. Whether the sacral motor neuron system is classified as upper or lower motor neuron injury is also quite useful and as such should be present in the ISCNSCI.

Positive sexuality in men with spinal cord injury.

STUDY DESIGN: Prospective study. OBJECTIVES: To analyze determinants of sexual pleasure in men with spinal cord injury (SCI). SETTING: Centre Bouffard-Vercelli, Cerbere, France. METHODS: Face to face interviews with men with chronic SCI who had an active sex life with a female partner, reliable erections permitting intercourse, and sought regular counselling with a sex therapist. Questionnaires: the International Index of Erectile Function (IIEF) and a modified Sexual History Form. RESULTS: Thirty-three men were enroled. IIEF subscores were high for erectile function (mean 27.6/30), sexual desire (mean 8.8/10), intercourse satisfaction (mean 11.9/15) and overall satisfaction (mean 8.7/10). Overall satisfaction was significantly related to the level (p < 0.01) but not the severity of the lesion (p = 0.59), positively correlated with intercourse satisfaction (p < 0.001), negatively with age (p < 0.05) and age at injury (p < 0.01), but not with time since injury (p = 0.80). Orgasm was reported by 14 men (42%), and correlated strongly with antegrade ejaculation (p < 0.001), but not with overall satisfaction (p = 0.81). All men, except one, described enjoyable, long foreplay. Intercourse was associated with sensations of pleasure for 30 men (90%). After intercourse, 26 men (78%) experienced sensations of fulfilment, and 30 (90%) of relaxation. Most men expressed frustration, primarily in the case of absent or intermittent ejaculation or orgasm. Men described their female partners as taking more initiatives, and having a satisfactory sex life. CONCLUSIONS: A positive and satisfying sex life is achievable by the men's willingness to adapt their sexual behaviour coupled with the reward of physical pleasure experienced during intercourse.

The importance of the bulbocavernosus reflex.

The BCR consists of the contraction of the bulbocavernosus muscle in response to squeezing the glans penis or clitoris, and is mediated through the pudendal nerve. In case of a complete lesion, the presence of BCR is indicative of intact S2-S4 spinal reflex arcs and loss of supraspinal inhibition, determining an upper motor neuron (UMN) lesion, its absence a lower motor neuron (LMN) lesion. The BCR further helps distinguish conus medullaris from cauda equina syndromes. Sensory or motor function in the most caudal sacral segments, not BCR, defines the sacral sparing as part of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Sphincter dysfunctions are addressed in the International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI). However, the ISAFSCI does not include the BCR, and is not part of the ISNCSCI. Yet, determination of the type of lesion, UMN or LMN, is very useful for the clinicians, and has important prognostic and therapeutic implications for bowel, bladder, and sexual function: UMN lesions are associated with detrusor and rectum hyperactivity, reflex erection and ejaculation, while the opposite is seen in patients with LMN lesions. BCR is complementary to the voluntary contraction of the external anal sphincter and should be added to ISNCSCI and ISAFSCI classifications, which should ultimately benefit patient care and research activities.

A 5-day antibiotic course for treatment of intermittent catheter-associated urinary tract infection in patients with spinal cord injury.

INTRODUCTION: This was a retrospective monocentric study conducted at Centre Calvé, France, with the objective of evaluating the effectiveness of a 5-day course of antibiotics for symptomatic (mild urinary tract infection, UTI) or asymptomatic (aBact) bacteriuria in patients with spinal cord injury on intermittent catheterization. CASE PRESENTATION: This study was conducted from May 2013 to September 2016. Antibiotic selection always followed culture collection and analysis of antibiograms. Patients with febrile UTI (>38°5) or recent history of urolithiasis were excluded. DISCUSSION: Fifty-seven patients underwent 111 5-day courses of antibiotics. The two main bacteria involved were Escherichia coli and Klebsiella Pneumoniae. Most commonly prescribed antibiotics were cephalosporins, cotrimoxazole, fluoroquinolones and nitrofurantoins. On day 4 of the antibiotic course, bacteria were eradicated in 99% of cases. Clinical cure occurred in all patients by day 5 (end of treatment). After treatment, recurrence of UTI occurred in 16% of patients at week 3, 38% at week 6 and 50% at week 9. This rate was not significantly different from patients initially treated for aBact (20%, 35% and 44%, respectively). The UTI-free period was significantly shorter after treatment for aBact (45.5 days) than after treatment for UTI (53.7 days). None of the following characteristics were found to be risk factors for UTI: level or severity of lesion, gender, voiding mode, use of anticholinergic drugs and time since lesion. Results of this study support the use of a short 5-day course of antibiotics to treat mild UTI in patients with spinal cord injury, and provide further evidence against treatment of aBact.

Intermittent catheterization acceptance test (I-CAT): A tool to evaluate the global acceptance to practice clean intermittent self-catheterization.

AIM: In certain cases, a patient's anxiety, fear, or misconceptions can represent significant obstacles to the learning of Clean Intermittent Self Catheterization (CISC), and little is known about these psychological barriers. The aim of the present study is thus to construct and validate an "Intermittent Catheterization Acceptance Test (I-CAT)" to evaluate the psychological acceptance of CISC. METHODS: A study was carried out in nine neuro-rehabilitation and urology departments in French university hospitals. Fifty-five items were identified, following a comprehensive review of the literature and cognitive debriefing interviews with patients. Following an initial expert panel meeting (EPM) with a French-speaking neuro-urology study group (GENULF), this list was refined and reduced to a draft I-CAT comprising 34 items. The face validity of the draft I-CAT was determined, and the results were then analyzed in a second EPM, leading to the elaboration of a second version of the I-CAT (23 items, 5 dimensions). Psychometric validation of this second version was established from a longitudinal, non-randomized study involving 201 neurological and non-neurological patients. Linguistic validation was carried out in English. RESULTS: Following the construct validity analyses, several items were deleted due to item overlap, ceiling effects, or poor content validity and 14 items were retained. Confirmatory factor analysis shows that this version has 2 dimensions. Cronbach's alpha was 0.93. The ICC demonstrated good test-retest reliability and satisfactory responsiveness. CONCLUSION: The upstream identification and solving of potential psychological barriers prior to the learning of CISC could improve patients' acceptance of this procedure.

Using the autonomic standards to assess orthostatic hypotension in persons with SCI: a case series.

INTRODUCTION: Spinal cord injury (SCI) creates a complex and unique syndrome of medical issues related to disruption of somatic and autonomic pathways. Among these impaired control of blood pressure (BP) can significantly impede patients' activities of daily living. The International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) is used to document the impact of SCI on resting BP (abnormal if below 90 mmHg) and the presence or absence of orthostatic hypotension (OH), defined as a symptomatic or asymptomatic decrease in BP (>/=20/10 mmHg) upon moving to an upright position. CASE PRESENTATION: Case 1 documents the adverse influence of prescribed medications (antidepressants for neuropathic pain) on OH; case 2 describes the influence of bladder management on cardiovascular instability (autonomic dysreflexia and subsequent OH); case 3 describes the association between spasticity and OH; case 4 describes OH associated with a Valsalva maneuver. DISCUSSION: Impaired control of BP can stem from a combination of medical issues and autonomic dysfunction in persons with SCI. Management strategies for OH will vary depending on the stage of the SCI, the root cause of the OH and other confounding medical conditions. Non-pharmacological treatment should be considered as a first line of intervention and consideration should be given to cessation of potentially contributory medications prior to implementing pharmaceutical interventions. The systematic use of ISAFSCI by clinicians is recommended to document BP irregularities and to describe the effects of treatment strategies aimed at improving BP control in the SCI population.

Oral midodrine for prostaglandin e1 induced priapism in spinal cord injured patients.

PURPOSE: We evaluated midodrine as oral treatment for pharmacologically induced priapism in spinal cord injured patients. MATERIALS AND METHODS: From 2004 to 2007 we treated 354 spinal cord injured patients with intracavernous injection of prostaglandin E1 to induce erection. Prolonged erection or priapism occurred in 14 cases (1.3% of intracavernous injections). High blood pressure and bradycardia (autonomic dysreflexia) were noted in 2 tetraplegic cases. Except in 2 patients oral midodrine was used as the only therapeutic approach to this event because of its alpha stimulant properties. RESULTS: All patients returned to the flaccid penile state within 30 to 45 minutes after midodrine administration. Oral midodrine was well tolerated with few side effects and without increasing the incidence of autonomic dysreflexia. At 6 months complete erection could be again induced by intracavernous injection in all treated patients. CONCLUSIONS: Midodrine administered orally is a simple and efficient treatment for the priapism induced by intracavernous injection of prostaglandin E1. It could be the first line therapeutic approach before more aggressive procedures.

Midodrine improves orgasm in spinal cord-injured men: the effects of autonomic stimulation.

INTRODUCTION: Orgasm is less frequent in men with spinal cord injury (SCI) than in able-bodied subjects, and is poorly understood. AIM: To assess the effect of autonomic stimulation on orgasm in SCI men using midodrine, an alpha1-adrenergic agonist agent. MATERIALS AND METHODS: Penile vibratory stimulation (PVS) was performed in 158 SCI men on midodrine as part of a treatment for anejaculation, after they failed a baseline PVS. A maximum of four trials were performed, weekly, with increasing doses of midodrine. MAIN OUTCOME MEASURE: The presence and type of ejaculation, orgasm experiences, and cardiovascular data were collected. RESULTS: Ejaculation either antegrade or retrograde was obtained in 102 SCI men (65%). Orgasm without ejaculation was reported by 14 patients (9%) on baseline PVS. Ninety-three patients (59%) experienced orgasm during PVS on midodrine. Orgasm was significantly related to the presence of ejaculation in 86 patients (84%), and more strikingly to antegrade ejaculation (pure or mixed with retrograde), i.e., in 98% of 70 patients. Orgasm was significantly more frequent in patients with upper motor neuron and incomplete lesions who present somatic responses during PVS. There was no effect of the presence of psychogenic erection. There was a significant increase in both systolic and diastolic blood pressure. Sixteen patients, mainly tetraplegics, developed intense autonomic dysreflexia (AD) that required an oral nicardipine chlorhydrate. CONCLUSIONS: Orgasm is the brain's cognitive interpretation of genital sensations and somatic responses, AD, and ejaculation. Intact sacral and T10-L2 cord segments are mandatory, allowing coordination between internal and external sphincters. Autonomic stimulation with midodrine enhances orgasm rate, mainly by creating antegrade ejaculation.

Baclofen intratecal no tratamento da espasticidade de origem medular / Intrathecal baclofen for the treatment of spinal spasticity

O objetivo deste trabalho foi avaliar a longo termo aspectosclínicos e técnicos do uso do baclofen intratecal por bomba deinfusão em pacientes portadores de espasticidade crônica deorigem medular.São analisados 122 pacientes portadores de espasticidademedular, operados entre 1989 e 2001, sendo 74 homens e 48mulheres, com média de idade de 45 anos, apresentando tempo deseguimento médio de cinco anos. Quanto à origem da lesãomedular, em 46 pacientes foi pós-traumática, em 52, por esclerosemúltipla e 24 pacientes tiveram outras causas (lesão pósoperatória,isquêmica ou pós-radioterapia).Todos os pacientes tiveram redução da hipertonia muscularcom diminuição dos espasmos dolorosos. Em 19 pacientes(15,6), o tratamento proposto resultou em melhora funcionaldo paciente. Nos outros 103 casos (84,4), a diminuição daespasticidade promoveu melhora objetiva no manejo do paciente,nos cuidados de enfermagem, de higiene pessoal e de transporte.De acordo com a escala de Ashworth, a pontuação média caiu de 3,0 para 1,4, enquanto na escala de freqüência de espasmo aqueda foi de 2,5 para 0,7. A dose média inicial de baclofen foi250 μg/dia, chegando progressivamente a 358 μg/dia, com grandevariabilidade individual. Complicações técnicas relacionadas aomaterial de implantação ocorreram em 36 casos (29,5) ecomplicações clínicas, relacionadas ao baclofen, foram observadasem 17 casos (13,9). Não houve óbitos relacionados aotratamento nesta série.O baclofen intratecal por bomba de infusão programável éuma modalidade terapêutica eficaz no tratamento da espasticidadecrônica de origem medular. O tratamento multidisciplinaré fundamental tanto na seleção como no acompanhamento dospacientes.