Identification of brain functional connectivity during acute transcutaneous tibial nerve stimulation: A 3T fMRI study.

OBJECTIVES: A feasibility proof-of-concept study was conducted to assess the effects of acute tibial nerve stimulation (TNS) on the central nervous system in healthy volunteers using functional magnetic resonance imaging (fMRI). MATERIALS AND METHODS: Fourteen healthy volunteers were included in a prospective, single-site study conducted on a clinical 3T MRI scanner. Four scans of functional MRI, each lasting 6 min, were acquired: two resting-state fMRI scans (prior and following the TNS intervention) and in-between two fMRI scans, both consisting of alternating rest periods and noninvasive acute transcutaneous TNS (TTNS). Whole brain seed-based functional connectivity (FC) correlation analysis was performed comparing TTNS stimulation with rest periods. Cluster-level familywise error (FWE) corrected p and a minimal cluster size of 200 voxels were used to explore FC patterns. RESULTS: Increased FC is reported between inferior frontal gyrus, posterior cingulate gyrus, and middle temporal gyrus with the precuneus as central receiving node. In addition, decreased FC in the cerebellum, hippocampus, and parahippocampal areas was observed. CONCLUSIONS: Altered FC is reported in areas which have been described to be also involved in lower urinary tract control. Although conducted with healthy controls, the assumption that the underlying therapeutic effect of TNS involves the central nervous system is supported and has to be further examined in patients with incomplete spinal cord injury.

Satisfaction with Homeopathic Service and Care for Persons with Spinal Cord Injury.

BACKGROUND: The aim of the study was to investigate the satisfaction of individuals with spinal cord injury (SCI) with a homeopathic service at an SCI rehabilitation center. PATIENTS AND METHODS: A cross-sectional questionnaire study was performed at an SCI rehabilitation center in Switzerland. It included patients with chronic SCI who presented themselves to a homeopathic service offered by the hospital in a 12-months period. The participants filled in standardized questionnaires in German: "Measure Yourself Medical Outcome Profile" (MYMOP), Treatment Satisfaction Questionnaire for Medication (TSQM-9), the European Project on Patient Evaluation of General Practice Care (EUROPEP) questionnaire, and a self-administered questionnaire. RESULTS: The data of 14 patients were analyzed. Symptom severity as well as bother by the symptoms that led to homeopathic treatment decreased under homeopathic treatment (severity: from 4.3 to 3.3; bother: from 4.2 to 2.9) and remained lower over time (severity: 2.6; bother: 2.7), suggesting a sustained effect. Irrespective of the test instrument used, satisfaction rates were higher for homeopathic service than for homeopathic medication, which was rated as successful by 50% of the participants. CONCLUSION: Persons with SCI suffering from secondary complications of SCI who accessed homeopathic care reported high satisfaction rates with the service. Therefore, homeopathic service can be considered as an additive measure in persons with SCI suffering from recurrent symptoms.Evaluierung der Zufriedenheit von Personen mit Querschnittlähmung (QSL) mit einer homöopathischen Betreuung an einem Rehabilitationszentrum für QSL.An einem Rehabilitationszentrum für QSL in der Schweiz wurde eine Querschnittserhebung mittels Fragebögen durchgeführt. Eingeschlossen wurden Personen mit chronischer QSL, die sich in einer von der Klinik angebotenen homöopathischen Sprechstunde in einem 12-Monats-Intervall vorstellten. Die Teilnehmenden füllten standardisierte Fragebogen in deutscher Sprache aus: "Measure Yourself Medical Outcome Profile" (MYMOP), Treatment Satisfaction Questionnaire for Medication (TSQM-9), den "European Project on Patient Evaluation of General Practice Care (EUROPEP)" Fragebogen sowie einen selbst-erstellten Fragebogen.Die Daten von 14 Teilnehmenden wurden ausgewertet. Der Schweregrad der Symptome sowie die Belastung durch die Symptome die zur homöopathischen Behandlung geführt haben, wurden unter der homöopathischen Therapie geringer (Schweregrad: von 4.3 auf 3.3; Belastung: von 4.2 auf 2.9) und blieben über den Untersuchungszeitraum geringer (Schweregrad: 2.6; Belastung 2.7), was einen anhaltenden Effekt nahelegt. Unabhängig von dem verwendeten Testinstrument waren die Zufriedenheitsraten für die homöopathische Betreuung höher als diejenigen für die homöopathische Medikation, die von 50% der Teilnehmenden als erfolgreich bewertet wurde.Personen mit QSL, die wegen Sekundärkomplikationen eine homöopathische Sprechstunde aufsuchten, berichteten eine hohe Zufriedenheit mit dieser Betreuung. Daher kann eine homöopathische Betreuung als zusätzliche Massnahme bei Personen mit QSL mit persistierender Symptomatik in Betracht gezogen werden.

Early Changes in Androgen Levels in Individuals with Spinal Cord Injury: A Longitudinal SwiSCI Study.

We aimed to explore longitudinal changes in androgen levels in individuals with spinal cord injury (SCI) within initial inpatient rehabilitation stay and identify clinical/injury characteristics associated with hormone levels. Linear regression analysis was applied to explore the association between personal/injury characteristics and androgen hormones (total testosterone, free testosterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S)) at admission to rehabilitation. Longitudinal changes in androgen levels were studied using linear mixed models. Analyses were stratified by sex and by injury type. We included 70 men and 16 women with SCI. We observed a non-linear association between age, time since injury, and androgens at baseline. At admission to initial rehabilitation, mature serum SHBG (full-length, protein form which lacks the N-terminal signaling peptide) was higher, while DHEA and DHEA-S were lower among opioid users vs. non-users. Serum levels of total testosterone and DHEA-S increased over rehabilitation period [ß 3.96 (95%CI 1.37, 6.56), p = 0.003] and [ß 1.77 (95%CI 0.73, 2.81), p = 0.01], respectively. We observed no significant changes in other androgens. Restricting our analysis to men with traumatic injury did not materially change our findings. During first inpatient rehabilitation over a median follow up of 5.6 months, we observed an increase in total testosterone and DHEA-S in men with SCI. Future studies need to explore whether these hormonal changes influence neurological and functional recovery as well as metabolic parameters during initial rehabilitation stay.

Management of stress urinary incontinence in female patients with spinal cord injury by autologous fascial sling: time for a revival?

STUDY DESIGN: This study is a retrospective chart analysis. OBJECTIVES: Surgical treatment of stress urinary incontinence (SUI) in women with neurogenic lower urinary tract dysfunction (NLUTD) is a challenge, as minimally invasive procedures do not seem to be effective, whereas synthetic implants are associated with substantial risks. Thus, we evaluated the results of an autologous sling procedure in this group of patients SETTING: This study was performed at a spinal cord injury rehabilitation center in Switzerland. METHODS: In this retrospective analysis, we evaluated the objective, subjective, and urodynamic results in women undergoing autologous sling insertion for SUI due to NLUTD at our institution. RESULTS: The data of 17 women who underwent fascial sling surgery were analyzed. After a median follow-up of 40 months, 8 women (47%) were continent, and another 8 patients (47%) significantly improved (1 pad/day). Median video-urodynamic parameters remained unchanged after sling insertion, but two women developed de novo detrusor overactivity. Postoperative complications occurred in 6 of the 17 patients (35.3%), which required surgical interventions in 2 women (12%) (urethral erosion by the sling and complete occlusion of the urethra after removal of the catheter), which could be resolved without loss of continence. CONCLUSION: In our case series, autologous fascial slings were effective in the treatment of SUI in women with NLUTD. As they are more effective than minimally invasive procedures, are associated with fewer complications than AUS, and seem to omit possible severe long-term consequences of synthetic slings, they are an excellent treatment option in this group of patients. Urodynamic controls are recommended, as de novo detrusor overactivity may occur after sling insertion.

Bladder management in individuals with spinal cord injury or disease during and after primary rehabilitation: a retrospective cohort study.

PURPOSE: The purpose of this study was to investigate the course of bladder evacuation and the predictors of intermittent self-catheterization (ISC) in individuals with neurogenic lower urinary tract dysfunction (NLUTD) during and after primary rehabilitation. METHODS: The patient database of a single spinal cord injury rehabilitation center was screened for patients with NLUTD admitted for primary rehabilitation. Patient characteristics and bladder evacuation details were collected during and after rehabilitation. Binary logistic regression analysis was used to evaluate predictors of ISC: sex, age > 65 years, injury severity, and bladder capacity ≥ 400 ml. RESULTS: Data of 255 men (74.3%) and 88 women (25.7%) with a mean age of 54 ± 19 years were analyzed. Early in rehabilitation, 21.6% of the evaluated individuals used ISC. In 17.8%, the bladder was evacuated by transurethral catheterization (TUC). The proportion of TUC decreased during rehabilitation and dropped below 2% at the last follow-up. In contrast, the proportion of ISC and suprapubic catheterization (SPC) increased to 28% and 12.8%, respectively, during rehabilitation. These proportions increased further thereafter and reached 37.7% and 18.6% for ISC and SPC, respectively. Age and injury severity were significant (p ≤ 0.041) negative predictors, whereas male sex and above-average bladder capacity were positive predictors of ISC. CONCLUSIONS: There is a shift toward bladder evacuation by ISC and SPC during and after primary rehabilitation. Bladder evacuation by ISC, regarded as the gold standard, is less common in individuals > 65 years or with high-level tetraplegia. The optimal bladder evacuation method needs to be established individually, considering all medical and psychosocial factors rather than simply following a guideline.

An instrument for assessing quality of life in persons with neurogenic lower urinary tract dysfunction: validation of the German short-form Qualiveen questionnaire.

STUDY DESIGN: Prospective validation study. OBJECTIVES: To validate and evaluate the measurement properties of the German Qualiveen short-form (SF) questionnaire in individuals with chronic neurogenic lower urinary tract dysfunction (NLUTD) resulting from spinal cord injury (SCI). SETTING: Tertiary neuro-urologic referral center in Switzerland. METHODS: Fifty individuals with chronic (>12 months) NLUTD resulting from SCI presenting for a urodynamic follow-up examination were enrolled to complete both the full version Qualiveen and the SF-Qualiveen questionnaires twice within three weeks. The criterion validity and test-retest reliability were evaluated by calculating the interclass correlation coefficients. Internal consistency was evaluated by calculating Cronbach's alpha. Finally, the cross-sectional construct validity was evaluated using Spearman's rank correlations between the scores of the two questionnaires for bladder evacuation, urinary continence, and urinary tract infection sub-groups. RESULTS: The mean age of the evaluated individuals was 53 years. The median duration of NLUTD was 14.9 years. The SF-Qualiveen showed good to excellent criterion validity with correlation coefficients greater than 0.8. Internal consistency was good overall and in the domains "bother with limitations" as well as "feelings" (>0.75). However, internal consistency in the domains "frequency of limitations" and "fears" was moderate-poor (0.68-0.37). The test-retest reliability was excellent with correlation coefficients greater than 0.9. Finally, the cross-sectional construct validity ranged from moderate to excellent (0.60-0.97). CONCLUSIONS: The German SF-Qualiveen has shown excellent reliability and validity and variable internal consistency. Its brevity will increase compliance, and we therefore recommend to include the SF-Qualiveen in urologic assessments.

Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction.

SNM for Urinary Tract DysfunctionThis study evaluated SNM for neurogenic lower urinary tract dysfunction. A neurostimulator was implanted for permanent stimulation and optimized using subsensory stimulation. It remained on or was switched off, with patients masked to the condition. After 2 months, the SNM ON group had significantly different success compared with the SNM OFF group (76% vs. 42%).

Risk Factors for Pulmonary Embolism in Patients with Paralysis and Deep Venous Thrombosis.

BACKGROUND: Venous thromboembolism is a frequent complication and an important cause of death in patients with paralysis. We aimed to investigate predictors of pulmonary embolism (PE) and the impact of PE on the survival of patients with paralysis in comparison to those with deep venous thrombosis or thrombophlebitis (DVT). METHODS: Patients were selected by screening the German nationwide inpatient sample (2005-2017) for paralysis, and were stratified for venous thromboembolism (VTE) and the VTE-sub-entity PE (ICD-code I26). Impact of PE on mortality and predictors for PE were analyzed. RESULTS: Overall, 7,873,769 hospitalizations of patients with paralysis were recorded in Germany 2005-2017, of whom 1.6% had VTE and 7.0% died. While annual hospitalizations increased (2005: 520,357 to 2017: 663,998) (ß 12,421 (95% CI 10,807 to 14,034), p < 0.001), in-hospital mortality decreased from 7.5% to 6.7% (ß -0.08% (95% CI -0.10% to -0.06%), p < 0.001). When focusing on 82,558 patients with paralysis hospitalized due to VTE (51.8% females; 58.3% aged ≥ 70 years) in 2005-2017, in-hospital mortality was significantly higher in patients with paralysis and PE than in those with DVT only (23.8% vs. 6.3%, p < 0.001). Cancer (OR 2.18 (95% CI 2.09-2.27), p < 0.001), heart failure (OR 1.83 (95% CI 1.76-1.91), p < 0.001), COPD (OR 1.63 (95% CI 1.53-1.72), p < 0.001) and obesity (OR 1.42 (95% CI 1.35-1.50), p < 0.001) were associated with PE. PE (OR 4.28 (95% CI 4.07-4.50), p < 0.001) was a strong predictor of in-hospital mortality. CONCLUSIONS: In Germany, annual hospitalizations of patients with paralysis increased in 2005-2017, in whom VTE and especially PE substantially affected in-hospital mortality. Cancer, heart failure, COPD, obesity and acute paraplegia were risk factors of PE.

Immunomodulation for primary prevention of urinary tract infections in patients with spinal cord injury during primary rehabilitation: protocol for a randomized placebo-controlled pilot trial (UROVAXOM-pilot).

BACKGROUND: Urinary tract infections (UTIs) are common in individuals with neurogenic lower urinary tract dysfunction (NLUTD) following spinal cord injury (SCI). They are not only a great burden for affected individuals, but also cause considerable health costs. Furthermore, recurrent antibiotic treatments of UTIs contribute to the growing problem of bacterial resistance to antimicrobial compounds. Even though there is a multitude of different measures to prevent UTIs in individuals with NLUTD, no clear evidence exists for any of these. Oral immunomodulation with UTI-relevant Escherichia coli lysate may be a promising preventative measure with a good safety profile in individuals with NLUTD. However, currently available data are sparse. METHODS: This is a randomized, quasi-blinded, placebo-controlled, mono-centric pilot trial investigating the feasibility of a main trial regarding the effects of a lyophilized lysate of E. coli strains for oral application (Uro-Vaxom®, OM Pharma SA, Meyrin, Switzerland). There will be two parallel groups of 12 participants each. Individuals with acute SCI (duration SCI ≤ 56 days) from 18 to 70 years of age admitted for primary rehabilitation will be eligible. Blood and urine samples will be taken prior to intervention start, at the end of the intervention, and 3 months after intervention termination. The trial intervention will last 90 days. The participants will not be informed regarding the treatment allocation (quasi-blinded). The nursing staff will prepare the daily dose of the allocated treatment from the original packaging. The trial personnel and the biostatistician will be blinded. Feasibility (e.g., recruitment rate, patient attrition), clinical (e.g., number of symptomatic UTIs), and laboratory parameters (e.g., urinary culture, urinary proteo- and microbiome, blood cell counts) as well as adverse events will be collected. DISCUSSION: Effective and efficient measures for the prevention of UTIs in individuals with NLUTD are urgently needed. If the conclusion of this pilot is positive regarding feasibility, the effects of oral immunomodulation with a E. coli lysate will be investigated in a larger, sufficiently powered, multi-center trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04049994 . Registered on 8 August 2019.

Changes in Bacterial Spectrum and Resistance Patterns Over Time in the Urine of Patients with Neurogenic Lower Urinary Tract Dysfunction Due to Spinal Cord Injury.

INTRODUCTION: Urinary tract infections (UTI) are among the most common complications in persons with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI). As both asymptomatic bacteriuria and UTI are frequently treated with antibiotics, concerns about multidrug resistance arise. Therefore, we analyzed the bacterial spectrum in the urine and the resistance patterns of the strains over time in patients with NLUTD due to SCI. METHODS: In a systematic chart review, we identified all microbiologic urine test results including resistance patterns of persons with SCI in a tertiary referral hospital at 2 time periods (2010-2011 and 2017-2018). We assessed the frequency of the bacterial strains, the resistance patterns of the 5 most frequent bacteria, and the use of antibiotics for in- as well as for outpatients. RESULTS: From 2010 to 2011, 1,308 (outpatients) and 2,479 (inpatients) bacterial strains were detected in the urinalyses performed; these numbers rose to 3,162 and 6,112 during 2017-2018, respectively. The most frequently detected bacteria during both time periods were Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae/variicola, Streptococcus viridans, Pseudomonas aeruginosa, and coagulase negative Staphylococci. Fluoroquinolones were the most frequently used antibiotics during both time periods. Despite its frequent use, no relevant increase in resistance against fluoroquinolones was detected. The most prominent increase in resistance appeared in E. coli against amocixillin/clavulanic acid in inpatients (from 26.0 to 38.5%). DISCUSSION AND CONCLUSIONS: Although fluoroquinolones were used frequently, we did not observe an increased resistance against these antibiotics over time in the urine of patients with SCI.

Are 200 units of onabotulinumtoxin A sufficient for the suppression of neurogenic detrusor overactivity in individuals with established 300-unit botulinum toxin treatment? A retrospective cohort study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To investigate the effects of 200-unit onabotulinumtoxin A detrusor injections on neurogenic detrusor overactivity (NDO) in patients who have previously been treated with 300-unit injections. SETTING: Tertiary urologic referral center in Switzerland. METHODS: The patient database was screened for patients with NDO as a result of chronic (≥ 12 months) spinal cord injury (SCI), who had been treated with 300- followed by 200-unit onabotulinumtoxin A detrusor injections. Patient characteristics, bladder management data and concurrent bladder medication as well as urodynamic data were collected. The percent changes in the urodynamic parameters from the 300- to the 200-unit treatment phase were calculated to test for non-inferiority of the 200-unit treatment. RESULTS: The data of 61 individuals with a mean age of 44 ± 15 years (range 18-73 years) and a mean 13.2 ± 9.5 years (range 2-43 years) since SCI were analyzed. The 200-unit treatment was not inferior regarding the urodynamic parameters compared to the 300-unit treatment. Furthermore, the proportion of patients with urinary incontinence was similar for both doses. There was no significant difference in the number of daily bladder evacuations (p = 0.13) or used incontinence pads (p = 0.43) between the two dosage phases. Moreover, there was no significant (p = 0.19) increase in the use of concurrent NDO medication (antimuscarinics or mirabegron) during the 200-unit treatment. CONCLUSIONS: The treatment of NDO with 200 units of onabotulinumtoxin A was not inferior to a 300-unit treatment regarding urodynamic parameters in patients with chronic SCI.

TASCI-transcutaneous tibial nerve stimulation in patients with acute spinal cord injury to prevent neurogenic detrusor overactivity: protocol for a nationwide, randomised, sham-controlled, double-blind clinical trial.

INTRODUCTION: Neurogenic lower urinary tract dysfunction (NLUTD), including neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia, is one of the most frequent and devastating sequelae of spinal cord injury (SCI), as it can lead to urinary incontinence and secondary damage such as renal failure. Transcutaneous tibial nerve stimulation (TTNS) is a promising, non-invasive neuromodulatory intervention that may prevent the emergence of the C-fibre evoked bladder reflexes that are thought to cause NDO. This paper presents the protocol for TTNS in acute SCI (TASCI), which will evaluate the efficacy of TTNS in preventing NDO. Furthermore, TASCI will provide insight into the mechanisms underlying TTNS, and the course of NLUTD development after SCI. METHODS AND ANALYSIS: TASCI is a nationwide, randomised, sham-controlled, double-blind clinical trial, conducted at all four SCI centres in Switzerland. The longitudinal design includes a baseline assessment period 5-39 days after acute SCI and follow-up assessments occurring 3, 6 and 12 months after SCI. A planned 114 participants will be randomised into verum or sham TTNS groups (1:1 ratio), stratified on study centre and lower extremity motor score. TTNS is performed for 30 min/day, 5 days/week, for 6-9 weeks starting within 40 days after SCI. The primary outcome is the occurrence of NDO jeopardising the upper urinary tract at 1 year after SCI, assessed by urodynamic investigation. Secondary outcome measures assess bladder and bowel function and symptoms, sexual function, neurological structure and function, functional independence, quality of life, as well as changes in biomarkers in the urine, blood, stool and bladder tissue. Safety of TTNS is the tertiary outcome. ETHICS AND DISSEMINATION: TASCI is approved by the Swiss Ethics Committee for Northwest/Central Switzerland, the Swiss Ethics Committee Vaud and the Swiss Ethics Committee Zürich (#2019-00074). Findings will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03965299.

Real-World Effects of Mirabegron in Patients with Chronic Neurogenic Detrusor Overactivity - A Retrospective Cohort Study.

PURPOSE: To investigate the tolerability and the effects of the ß-3-adrenoceptor-agonist mirabegron on urinary incontinence and urodynamic parameters in patients with chronic neurogenic detrusor overactivity (NDO). PATIENTS AND METHODS: The patient database of a spinal cord injury rehabilitation center in Switzerland was screened for patients with chronic (>12 months) NDO, who had been prescribed mirabegron. Patient characteristics, data regarding bladder management, urinary incontinence and concurrent medication for NDO as well as urodynamic parameters were collected retrospectively. The changes in the urodynamic parameters and the occurrence of urinary incontinence over time were investigated. RESULTS: The data of 63 patients with a median age of 48 years and a median NDO duration of 8.9 years at the initiation of the mirabegron treatment were analyzed. A median 3.0 and 12.7 months had elapsed from the initiation of the mirabegron therapy to the first and second follow-up evaluation, respectively. The majority of patients (73%) received mirabegron in combination with an established antimuscarinic or onabotulinum toxin therapy. The number of patients suffering from urinary incontinence decreased significantly (p≤0.005) from 60.3% (95% CI 47.2/72.4%) to 38.1% (95% CI 23.6/54.4%). Furthermore, the maximum detrusor pressure during the storage phase was significantly (p≤0.04) lower at the second follow-up evaluation (29.5cmH2O, 95% CI 22/40cmH2O) compared to before the mirabegron treatment (35cmH2O, 95% CI 29/41cmH2O). The bladder capacity and detrusor compliance were significantly (p≤0.005) increased during the mirabegron treatment. No patient had discontinued the mirabegron treatment as a result of side effects. CONCLUSION: Mirabegron demonstrated a clinically relevant effect and a good safety profile. Concomitant treatment of NDO with mirabegron may allow reduction in the dose of antimuscarinic medication and thus, improve the long-term persistence of NDO treatment.

The Challenge of Asymptomatic Bacteriuria and Symptomatic Urinary Tract Infections in Patients with Neurogenic Lower Urinary Tract Dysfunction.

PURPOSE: We investigated the prevalence of asymptomatic bacteriuria and the incidence of symptomatic urinary tract infections in patients with neurogenic lower urinary tract dysfunction undergoing urodynamics. We also assessed predictors of symptomatic urinary tract infections. MATERIALS AND METHODS: We evaluated a prospective consecutive series of 317 patients, including 106 women and 211 men, with neurogenic lower urinary tract dysfunction. Of the patients 111 (35%) voided spontaneously, 141 (44%) relied on intermittent self-catheterization and 65 (21%) relied on an indwelling catheter. Before urodynamics the urine samples were collected by sterile catheterization for dipstick testing and urine culture. We assessed the association of patient characteristics with symptomatic urinary tract infections after urodynamics in patients with asymptomatic bacteriuria and developed a prediction model based on the most important risk factors. RESULTS: Before urodynamics urine cultures were negative in 123 patients (39%) and positive in 194 (61%). Escherichia coli and Klebsiella pneumoniae were the most frequent bacteria, found in 32% and 18% of patients, respectively. Of 194 patients with a positive culture 35 (18%) had at least 1 symptomatic urinary tract infection. In patients with a history of previous urinary tract infections the overall estimated probability of a symptomatic urinary tract infection was 45% regardless of the underlying neurological disorder. CONCLUSIONS: A symptomatic urinary tract infection will develop in the followup year in about 1 of 5 patients with asymptomatic bacteriuria. This rather low overall probability precludes routine antibiotic prophylaxis or treatment in patients with neurogenic lower urinary tract dysfunction who have asymptomatic bacteriuria since 4 of 5 would be overtreated. However, in patients with a history of previous symptomatic urinary tract infections antibiotic prescription might be justified.

Extended periprostatic nerve distributions on the prostate surface confirmed using diffusion tensor imaging.

OBJECTIVE: To perform a descriptive microscopic study of prostatectomy specimens from 19 patients which anatomically characterizes the distributions of periprostatic nerve qualities, and to visualize these using diffusion tensor imaging (DTI). MATERIALS AND METHODS: Serial whole-mounted sections were stained for cholinergic (neuronal nitric oxide synthase), adrenergic (tyrosine hydroxylase) and sensory (calcitonin gene-related peptide) nerves. Extracapsular stained nerves were counted by prostate surface sector, and classified by diameter. Stain-related relative density was calculated, and distribution patterns were evaluated. To better visualize the reported neuronal structures and independently confirm our findings, nerve concordance in five male volunteers was investigated using a 3-Tesla magnetic resonance imaging-DTI system. RESULTS: At the base, cholinergic nerves were distributed from the anterolateral to posterior sectors, continuing posterolaterally (mid-section) into the posterolateral-posterior sector toward the apex. Adrenergic nerves were distributed across the anterolateral-posterior sectors at the base, with the course narrowing to the posterolateral-posterior sectors at the mid- and apical levels. Sensory fibres were found posterolaterally posteriorly at the base, continuing posterolaterally over the mid- and apical levels. Although it was not possible to determine the different nerve qualities, DTI confirmed histological findings from the base to the apex. CONCLUSIONS: Different types of nerve fibres were found to vary in distribution. When linked to possible functional aspects of the different nerve types, this morphological evidence may be of importance to further protect function after radical prostatectomy (RP). To our knowledge, this is the first time that DTI has confirmed reported histological findings in nerve-sparing RPs. DTI could be an important tool with which to correlate nerves to tumour for better preoperative planning and to incorporate imaging into treatment.

Usefulness of classical homeopathy for the prophylaxis of recurrent urinary tract infections in individuals with chronic neurogenic lower urinary tract dysfunction.

Context/Objective: to investigate the usefulness of classical homeopathy for the prevention of recurrent urinary tract infections (UTI) in patients with spinal cord injury (SCI). Design: prospective study. Setting: rehabilitation center in Switzerland. Participants: patients with chronic SCI and ≥3 UTI/year. Interventions: Participants were treated either with a standardized prophylaxis alone or in combination with homeopathy. Outcome measures: The number of UTI, general and specific quality of life (QoL), and satisfaction with homeopathic treatment were assessed prospectively for one year. Results: Ten patients were in the control group; 25 patients received adjunctive homeopathic treatment. The median number of self-reported UTI in the homeopathy group decreased significantly, whereas it remained unchanged in the control group. The domain incontinence impact of the KHQ improved significantly (P = 0.035), whereas the general QoL did not change. The satisfaction with homeopathic care was high. Conclusions: Adjunctive homeopathic treatment lead to a significant decrease of UTI in SCI patients. Therefore, classical homeopathy could be considered in SCI patients with recurrent UTI. Trial registration: ClinicalTrials.gov. (NCT01477502).

Treatment of Complicated Urinary Tract Infections in Individuals with Chronic Neurogenic Lower Urinary Tract Dysfunction: Are Antibiotics Mandatory?

INTRODUCTION: Urinary tract infections (UTI) in patients with neurogenic lower urinary tract dysfunction (NLUTD) are defined as complicated UTI requiring antibiotic treatment. As the emergence of multiresistant strains is a serious problem, we assessed the feasibility of nonantibiotic treatment of UTI in patients with NLUTD. MATERIALS AND METHODS: In a prospective study evaluating the usefulness of UTI prophylaxis, participants could opt for either antibiotic or nonantibiotic treatment of breakthrough UTI. If either symptoms persisted for 48 h or a febrile UTI occurred, antibiotic treatment based on microbiological testing was mandatory. Treatment efficacy, complications, and emergency hospital visits were assessed. RESULTS: Within the observation period (1 year), the 25 participants developed 206 UTI. Seven febrile UTI required immediate antibiotic treatment. Of the remaining 199 UTI, patients chose antibiotic treatment in 104 events, whereas in 95 events, patients chose either nonantibiotic interventions (n = 80) or no treatment at all (n = 15). Success rates were 78.8% for antibiotic treatment, 67.5% with nonantibiotic treatments, and 26% without therapy. Of the 7 patients with initially febrile UTI, 2 required hospitalization due to septicemia. CONCLUSIONS: Nonantibiotic treatment seems to be a feasible alternative to antibiotic therapy in patients with complicated UTI as well, provided there is no fever.

[A rare complication of transrectal electrostimulation for sperm retrieval]. / Das ist doch kein Beinbruch?! Eine seltene Komplikation der transrektalen Elektrostimulation zur Spermagewinnung.

In men who wish to have children after a spinal cord injury, assisted ejaculation is frequently needed for sperm retrieval. Transrectal electrostimulation (TES) is often used for this purpose. Typical side effects of TES are autonomic dysreflexia or pain. In a 33-year old man with complete tetraplegia below C6 since 2004, TES caused massive leg spasticity, leading to transcervical fracture of the femoral neck. This previously unreported complication of TES demonstrates that, in men with long-term chronic tetraplegia, spasticity and osteoporosis, TES in anesthesia should be taken into consideration.

Clinical usefulness of urine cytology in the detection of bladder tumors in patients with neurogenic lower urinary tract dysfunction.

INTRODUCTION: Screening for bladder cancer in patients with neurogenic lower urinary tract dysfunction is a challenge. Cystoscopy alone is not sufficient to detect bladder tumors in this patient group. We investigated the usefulness of combined cystoscopy and urine cytology. MATERIALS AND METHODS: By a systematic chart review, we identified all patients with neurogenic lower urinary tract dysfunction who underwent combined cystoscopy and urine cytology testing. In patients with suspicious findings either in cytology or cystoscopy, transurethral resection was performed. RESULTS: Seventy-nine patients (age 54.8±14.3 years, 38 female, 41 male) were identified; 44 of these used indwelling catheters. Cystoscopy was suspicious in 25 patients and cytology was suspicious in 17 patients. Histologically, no tumor was found in 15 patients and bladder cancer was found in 6 patients. Sensitivity for both cytology and cystoscopy was 83.3%; specificity was 43.7% for cytology and 31.2% for cystoscopy. One bladder tumor was missed by cytology and three tumors were missed by cystoscopy. If a biopsy was taken only if both findings were suspicious, four patients would have been spared the procedure, and one tumor would not have been diagnosed. CONCLUSION: A combination of cystoscopy and urine cytology can improve bladder tumor detection rates and lower the number of unnecessary biopsies.

Management of urinary tract infections in patients with neurogenic bladder: challenges and solutions.

INTRODUCTION: Urinary tract infections (UTIs) are one of the most common morbidities in persons with neurogenic lower urinary tract dysfunction (NLUTD). They are associated with a significant morbidity and mortality, and they affect the quality of life of the affected patients. Diagnosis and treatment of UTI in this group of patients are challenging. In this review, the current strategies regarding diagnosis, treatment, and prevention are summarized. DIAGNOSTICS: it is important to correctly diagnose a UTI, as treatment of bacteriuria should strictly be avoided. A UTI is defined as a combination of laboratory findings (leukocyturia and bacteriuria) and symptoms. Laboratory findings without symptoms are classified as asymptomatic bacteriuria. Routine urine screening is not advised. TREATMENT: Only UTI should be treated; treatment of asymptomatic bacteriuria is not indicated. Prior to treatment, urine for a urine culture should be obtained. Antibiotic treatment for ~7 days is advised. PREVENTION: In recurrent UTI, bladder management should be optimized and morphologic causes for UTI should be excluded. If UTIs persist, medical prophylaxis should be considered. Currently, no prophylactic measure with evidence-based efficacy exists. Long-term antibiotic prophylaxis should be used merely as an ultimate measure. Among the various mentioned innovative approaches for UTI prevention, bacteriophages, intravesical instillations, complementary and alternative medicine techniques, and probiotics seem to be most promising. CONCLUSION: Recently, several promising innovative options for UTI prophylaxis have been developed which may help overcome the current therapeutic dilemma. However, further well designed studies are necessary to evaluate the safety and efficacy of these approaches.