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.

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.

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.

Human spinal ejaculation generator.

OBJECTIVE: A spinal ejaculation generator (SEG) has been identified in the rat with lumbar galaninergic interneurons playing a pivotal role (Science 2002;297:1566-1569). The aim was to evidence a SEG in humans. METHODS: Spatial distribution of galaninergic neurons was studied in postmortem spinal cord segments of 6 men and compared with that of 6 women for evidencing sexual dimorphism. Based on the identified segmental distribution of galaninergic neurons, the ability for penile vibratory stimulation (PVS) to elicit ejaculation when the concerned spinal segments were injured was studied in 384 patients with clinically complete spinal cord injury (SCI) and consequent anejaculation. Such patients represent a unique model to investigate the role of defined spinal segments in the control of ejaculation. RESULTS: Galaninergic neurons were mostly located between L2 and L5 segments in medial lamina VII, with a maximal density within L4. Three-dimensional 3D reconstruction showed that these neurons were grouped into single columns bilaterally to the central canal. In addition, galaninergic neuron density was found higher in L3 and L4 segments in men as compared to women supporting sexual dimorphism. In the patients' cohort, injury of L3-L5 segments was the sole independent predictor for failure of PVS to induce ejaculation. Although evidence from clinical observations was indirect, there is close correspondence to neuroanatomical data. INTERPRETATION: Organization and sexual dimorphism of human spinal galaninergic neurons were similar to the rat's SEG. Neurohistological data, together with clinical results, corroborate the existence of an SEG in humans in L3-L5 segments. Such a generator could be targeted to treat neurogenic and non-neurogenic ejaculatory disorders. ANN NEUROL 2017;81:35-45.

[Highlighting differences in the management of neurogenic bladder existing between urologists and physiatrists: A survey conducted among 383 specialists]. / Mise en évidence des différences de gestion des vessies neurologiques existantes entre urologues et médecins spécialisés en médecine physique et de réhabilitation : enquête réalisée auprès de 383 spécialistes.

OBJECTIVES: To investigate and evaluate the quality of care and follow-up provided to neurogenic patients by urologists and physiatrists in France. METHODS: A survey was conducted by the French-speaking group of neuro-urology (GENULF) among French urologists and physiatrists in 2009. Three thousand one hundred and eighty questionnaires were sent to the members of four scientific societies. Questions focused on aetiology, consultation, clinical follow-up and symptom management. RESULTS: Two hundred and seventy-four urologists and 109 physiatrists completed the questionnaire, 76% and 84% respectively had experience in neuro-urology. Only a few specialists performed multidisciplinary consultations. Systematic follow-up frequency varied between 6 to 12 months. Eighty-three percent of physiatrists and 56% of urologists performed a urodynamic follow-up, mostly yearly. Physiatrists used invasive imaging techniques more often than urologists. They also treated asymptomatic bacteriuria in catheterised patients more often than urologists. Self-catheterisation was a standard treatment to address urinary retention. Both specialists prescribed botulinum toxin type A injections. DISCUSSION: National and international guidelines related to follow-up and treatments were followed by both specialists. Urologists and physiatrists treated asymptomatic bacteriuria more often than necessary. Urodynamics testing was not carried out as often as recommended by guidelines. Urologists offered a more frequent follow-up than physiatrists. Physiatrists performed more often and better urodynamic follow-up compared to urologists. CONCLUSION: Our survey revealed a good observance of national and international guidelines by French specialists for the management of neurogenic bladder patients. Nevertheless, the management of these patients could be harmonised and possibly improved by putting an accent on specialists' education, by using assessment forms regarding their practices and by increasing the amount of multidisciplinary consultations.

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.

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES: Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS: A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. RESULTS: A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events. CONCLUSIONS: Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

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.

Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES: This systematic literature review discusses the efficacy and safety of botulinum toxin type A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS: A MEDLINE and EMBASE search for clinical studies with botulinum toxin A injected into the detrusor of adults with NDO was performed. For several efficacy and safety variables data were extracted by one person and independently quality-controlled by another person. Extracted data were reviewed to propose recommendations for use in clinical practice based on level of evidence and expert opinion. RESULTS: A total of 18 articles evaluating the efficacy or safety of Botox in patients with NDO and incontinence/NOAB resistant to antimuscarinic therapy, with or without clean intermittent self-catheterisation (CIC), were selected. The amount of Botox injected was mostly 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and with different types of anaesthesia. Most of the studies reported a significant improvement in clinical (approximately 40-80% of patients became completely dry between CICs) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to < or =40 cm H(2)O) variables and in the patients' quality of life, without major adverse events. CONCLUSIONS: Botox injections into the detrusor provide a clinically significant improvement in adults with NDO and incontinence/NOAB refractory to antimuscarinics. It seems to be very well tolerated. However, more adequately powered, well-designed, randomised, controlled studies evaluating the optimal dose, number and location of injections, impact on antimuscarinic regimen and CIC use, duration of effect, and when to perform repeat injections are warranted.

[Comparative study of the acceptability of the SpeediCath Set and Actreen set catheterization sets in patients performing self-catheterization]. / Etude d'acceptabilité du set de sondage SpeediCath Set comparativement à Actreen Set chez des patients pratiquant l'autosondage.

OBJECTIVE: To compare SpeediCath Set to Actreen Set in terms of performance, acceptability and safety, in patients performing self-catheterization. MATERIAL AND METHODS: Four questionnaires were completed during this multicentre, randomized, crossover study: initial, after having tested each of the two products and patient preference at the end of the study. RESULTS: Analysis was based on 29 men performing self-catheterization. The SpeediCath Set was found to be superior to the Actreen Set in terms of ease of introduction (p=0.0055), ease of emptying (p=0.0157), quality of lubricant (p<0.0001), urethral tolerance and possibility of catheterization in bed (p= 0.0157). The patients 'global assessment was clearly in favour of SpeediCath Set (70 +/- 2.3 versus 5.7 +/- 2.5; p=0.0156) and 65.5% of patients preferred to use SpeediCath Set in the future. CONCLUSION: SpeediCath Set facilitates catheterization and improves the urethral tolerance compared to Actreen Set, with a marked patient preference in favour of SpeediCath Set.

[Neurogenic bladder: pathophysiology of the disorder of compliance]. / Vessie neurogène : physiopathologie du trouble de compliance.

Bladder compliance is defined by the ratio of the increase of intravesical pressures to the increase of volume (_V/_P). The pathophysiology of disorders of compliance in neurogenic bladder is still poorly elucidated. It can be evaluated in terms of three elements: 1) The natural history of the appearance of these disorders in neurogenic bladders. Clinical experience shows the existence of prognostic factors that determine the development of these disorders, such as the voiding mode adopted (self-catheterization/hetero-catheterization versus indwelling catheter), the level of the spinal cord lesion (suprasacral versus sacral, incomplete versus complete, and cauda equina lesions), and the presence of meningomyelocele. 2). Data derived from conservative management of these disorders in neurogenic bladders: urethral dilatation, various sphincterotomies, bladder disafferentation, alpha-blockers, vanilloids (resiniferatoxin and capsaicin), intra-detrusor botulinum toxin and intrathecal baclofen, have demonstrated a marked improvement of disorders of compliance associated with neurogenic bladder 3). Data derived from experimentations. Morphometric studies on animal or human bladder strips have demonstrated an increased expression of proteolytic enzymes and endogenous tissue inhibitors of metalloproteinases (MMP-1) and type III collagen mRNA in hypocompliant neurogenic bladders. Reduction of bladder wall blood flow, bilateral section of hypogastric nerves in rats, study of the bladders of spinalized rats, and reduction of oestrogenic hormone impregnation, show that these conditions induce loss of the viscoelastic properties of the bladder With the arrival of new treatments, active on afferent and/or efferent pathways or even on the central nervous system, it is very important to further our understanding of the pathophysiology of disorders of compliance in neurogenic bladders. Reversibility of these disorders constitutes a major therapeutic challenge and its functional consequences make it a critical prognostic factor for the outcome of neurogenic bladder