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1.
Bone Joint J ; 102-B(5): 556-567, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32349600

RESUMO

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556-567.


Assuntos
Síndrome do Músculo Piriforme/diagnóstico , Síndrome do Músculo Piriforme/terapia , Ciática/diagnóstico , Ciática/terapia , Terapia Combinada , Diagnóstico Diferencial , Diagnóstico por Imagem , Eletrodiagnóstico , Humanos , Anamnese , Exame Físico , Síndrome do Músculo Piriforme/fisiopatologia , Nervo Pudendo/fisiopatologia , Nervo Isquiático/fisiopatologia , Ciática/fisiopatologia
2.
Urology ; 137: 196-199, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31738943

RESUMO

OBJECTIVE: To describe a novel technique of using peripheral nerve neuromodulation (PNNM) for the treatment of refractory, mesh-induced chronic pelvic pain. Chronic pelvic pain associated with mesh can be a debilitating complication and there is currently no consensus on treatment. PNNM has been shown to be successful in the treatment of post-traumatic neuralgias but has yet to be studied in mesh complications. MATERIALS AND METHODS: We present a case of a 50-year-old woman who had unrelenting pelvic pain after retropubic sling placement. She failed multiple therapies including medications, mesh removal, pelvic floor physical therapy, pudendal neuromodulation, and pelvic floor onabotulinumtoxinA trigger point injections. RESULTS: The only treatment that provided temporary relief of this patient's pain was transvaginal trigger point injections along with a right pudendal nerve block using 40 mg triamcinolone and 0.5% ropivacaine. To help define if treatment at the site of her pain would provide relief, a series of blocks were done by advancing a needle retropubically to her area of pain and injecting triamcinolone and 0.5% ropivacaine. This injection, which corresponded to the previous tract of her retropubic sling, provided temporary, but profound, relief. PNNM was then done with placement of the electrode in the retropubic space at the site of her pain. This provided instantaneous relief of almost all of her pain symptoms. Twelve months postoperatively, the patient continued to have >90% improvement in her pain. CONCLUSION: Focused PNNM is a simple procedure and can provide symptomatic relief for refractory postvaginal mesh pain.


Assuntos
Dor Pélvica , Complicações Pós-Operatórias , Implantação de Prótese , Neuralgia do Pudendo , Estimulação Elétrica Nervosa Transcutânea/métodos , Incontinência Urinária por Estresse/cirurgia , Dor Crônica , Remoção de Dispositivo/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Dor Pélvica/diagnóstico , Dor Pélvica/etiologia , Dor Pélvica/terapia , Períneo/inervação , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/métodos , Nervo Pudendo/fisiopatologia , Neuralgia do Pudendo/diagnóstico , Neuralgia do Pudendo/etiologia , Neuralgia do Pudendo/terapia , Slings Suburetrais/efeitos adversos , Telas Cirúrgicas/efeitos adversos , Resultado do Tratamento , Pontos-Gatilho
3.
Int J Colorectal Dis ; 35(2): 361-364, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31828369

RESUMO

BACKGROUND: Pudendal and cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Recently, a new endoscopic minimal invasive approach for pudendal and inferior cluneal nerve neurolysis has been published in a cadaver study. The aim of our study was to describe the feasibility of this new approach and to evaluate the clinical outcome. METHODS: Fifteen patients underwent the ENTRAMI technique. The Numeric Pain Rating Scale (NPRS) and Patient Global Impression of Change (PGIC) were recorded at baseline and at 3 and 6 months after surgery. RESULT: The average duration of intervention (skin to skin) was 139 min (range 50-270 min) for bilateral pudendal neurolysis and/or cluneal neurolysis and 113 min (range 100-130 min) for unilateral pudendal and/or cluneal neurolysis. No perioperative blood loss occurred. At 3 months, 50% of patients declared a more than 30% improvement of their PGIC, increasing to 57% at 6 months; 31% reported more than 90% improvement of PGIC at 6 months. Overall reduction of the average maximal NPRS score was from 9 (range 7-10) to 6 at 3 months (range 0-10; p value < 0.05) and to 5 at 6 months (range 0-10; p value < 0.05). There were no postoperative complications. CONCLUSIONS: The ENTRAMI technique is feasibly in patients suffering from pudendal and/or cluneal neuralgia and preliminary results are promising. CLINICAL TRIAL NUMBER: NCT03883178.


Assuntos
Dor Crônica/cirurgia , Endoscopia , Neuralgia/cirurgia , Períneo/inervação , Nervo Pudendo/cirurgia , Neuralgia do Pudendo/cirurgia , Adulto , Idoso , Dor Crônica/diagnóstico , Dor Crônica/fisiopatologia , Endoscopia/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neuralgia/diagnóstico , Neuralgia/fisiopatologia , Nervo Pudendo/fisiopatologia , Neuralgia do Pudendo/diagnóstico , Neuralgia do Pudendo/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
4.
Neurourol Urodyn ; 39(2): 658-664, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31793050

RESUMO

INTRODUCTION: Urological chronic pelvic pain syndrome (UCPPS) represents a group of pain symptoms relating to patients with pelvic pain for which treatment is largely unsatisfactory. The objective of this study is to analyze the effects of a novel treatment strategy in males suffering from UCPPS. METHODS: This retrospective, institutional review board-approved study analyzed eight male patients aged 24 to 61 with UCPPS. All the patients had a trial of antibiotic therapy, NSAIDs, and pelvic floor physical therapy before the study. The Visual Analog scale (VAS) and Functional Pelvic Pain scale (FPPS) were collected pretreatment. While continuing physical therapy, patients underwent weekly ultrasound-guided pelvic floor trigger point injections to the iliococcygeus, pubococcygeus, and puborectalis with lidocaine 1%. Concomitantly, patients received peripheral nerve hydrodissection performed on the pudendal nerve and the posterior femoral cutaneous nerve. The first two injections combined 1% lidocaine with dexamethasone, while the next four injections consisted of 1% lidocaine with traumeel (a homeopathic, plant-derived anti-inflammatory medication). At the 6-week follow-up, each patient retook the VAS and FPPS. RESULTS: The mean age of our patients was 31.8 years and the average duration of symptoms of the UCPPS was 21 months. Pretreatment, the mean VAS was 3.3 (STD 1.7) and the mean VAS posttreatment was 1.8 (STD 1.4); P < .05; 95% CI, 0.73 to 2.27. The mean FPPS pretreatment was 11.0 (STD 8.0) and the mean FPPS posttreatment was 6.3 (STD 5.3); P < .05; 95% CI, 0.03 to 9.22. CONCLUSION: Our results show promise for a novel, nonopioid-based treatment for UCPPS.


Assuntos
Dor Crônica/tratamento farmacológico , Lidocaína/uso terapêutico , Dor Pélvica/tratamento farmacológico , Adulto , Dor Crônica/diagnóstico , Dor Crônica/fisiopatologia , Feminino , Humanos , Lidocaína/administração & dosagem , Masculino , Pessoa de Meia-Idade , Medição da Dor , Diafragma da Pelve/fisiopatologia , Dor Pélvica/diagnóstico , Dor Pélvica/fisiopatologia , Modalidades de Fisioterapia , Nervo Pudendo/fisiopatologia , Estudos Retrospectivos , Pontos-Gatilho , Ultrassonografia de Intervenção , Escala Visual Analógica , Adulto Jovem
5.
Am J Physiol Renal Physiol ; 317(4): F1047-F1057, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31411077

RESUMO

Stress urinary incontinence (SUI) is more prevalent among women who deliver vaginally than women who have had a cesarean section, suggesting that tissue repair after vaginal delivery is insufficient. A single dose of mesenchymal stem cells (MSCs) has been shown to partially restore urethral function in a model of SUI. The aim of the present study was to determine if increasing the number of doses of MSCs improves urethral and pudendal nerve function and anatomy. We hypothesized that increasing the number of MSC doses would accelerate recovery from SUI compared with vehicle treatment. Rats underwent pudendal nerve crush and vaginal distension or a sham injury and were treated intravenously with vehicle or one, two, or three doses of 2 × 106 MSCs at 1 h, 7 days, and 14 days after injury. Urethral leak point pressure testing with simultaneous external urethral sphincter electromyography and pudendal nerve electroneurography were performed 21 days after injury, and the urethrovaginal complex and pudendal nerve were harvested for semiquantitative morphometry of the external urethral sphincter, urethral elastin, and pudendal nerve. Two and three doses of MSCs significantly improved peak pressure; however, a single dose of MSCs did not. Single, as well as repeated, MSC doses improved urethral integrity by restoring urethral connective tissue composition and neuromuscular structures. MSC treatment improved elastogenesis, prevented disruption of the external urethral sphincter, and enhanced pudendal nerve morphology. These results suggest that MSC therapy for postpartum incontinence and SUI can be enhanced with multiple doses.


Assuntos
Doenças Neuromusculares/terapia , Transplante de Células-Tronco/métodos , Uretra/fisiopatologia , Incontinência Urinária por Estresse/terapia , Animais , Transplante de Medula Óssea/métodos , Tecido Conjuntivo/patologia , Elastina/metabolismo , Feminino , Transplante de Células-Tronco Mesenquimais/métodos , Compressão Nervosa , Doenças Neuromusculares/complicações , Doenças Neuromusculares/fisiopatologia , Período Pós-Parto , Nervo Pudendo/fisiopatologia , Ratos , Ratos Sprague-Dawley , Uretra/inervação , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/fisiopatologia , Vagina/lesões
6.
Colorectal Dis ; 21(11): 1296-1303, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31271490

RESUMO

AIM: The ability of patients with poor pudendal nerve function to voluntarily contract their external anal sphincter is limited. However, it is not known whether the condition of the pudendal nerve influences voluntary puborectal muscle contraction. Recently, we described the puborectal continence reflex that maintains faecal continence by involuntary contractions of the puborectal muscle. We aim to investigate whether both voluntary and involuntary contractions of the puborectal muscle are influenced by the condition of the pudendal nerve. METHOD: We retrospectively analysed 129 adult patients who underwent anorectal function tests at the Anorectal Physiology Laboratory. Anal electrosensitivity was used as a measurement of the pudendal nerve function. Voluntary and involuntary contractions of the puborectal muscle were defined as maximum puborectal muscle contractility and maximum pressure at the level of the puborectal muscle during the balloon retention test. RESULTS: Voluntary contraction of the puborectal muscle was significantly decreased in patients with pudendal nerve damage (P = 0.002). Involuntary contractions, however, were not associated with the condition of the pudendal nerve (P = 0.63). Multiple linear regression analysis showed that the condition of the pudendal nerve and patients' sex significantly predicted voluntary contraction but not involuntary contraction. CONCLUSION: Voluntary contractions of the puborectal muscle are significantly decreased in patients with pudendal nerve damage, while involuntary contractions of the puborectal muscle are comparable to those of patients without nerve damage. We conclude that the puborectal continence reflex, which controls involuntary contractions of the puborectal muscle, is not regulated by the pudendal nerve.


Assuntos
Canal Anal/fisiopatologia , Incontinência Fecal/fisiopatologia , Doenças do Sistema Nervoso Periférico/fisiopatologia , Nervo Pudendo/fisiopatologia , Reflexo Anormal/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Canal Anal/inervação , Defecação/fisiologia , Incontinência Fecal/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Doenças do Sistema Nervoso Periférico/complicações , Pressão , Reflexo , Estudos Retrospectivos , Adulto Jovem
7.
Neurourol Urodyn ; 38(1): 223-230, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30311682

RESUMO

AIM: Idiopathic overactive bladder (OAB) is a prevalent, mystifying disorder with a questionable neurogenic background. We aimed to investigate the possible subtle neuropathic affection underlying its pathogenesis. METHODS: A cross-sectional cut off study was carried out on a series of 38 females with idiopathic OAB and 22 healthy matched female volunteers. The following was performed: symptom score questionnaire, determination of pudendal nerve terminal motor latency (PNTML), sacral reflexes' latencies, pudendal somatosensory evoked potentials, and needle electromyography of the external anal and urethral sphincters. RESULTS: A highly significant prolongation of PNTMLs and sacral reflexes latencies among the patients group was detected (P ≥ 0.001). Pudendal somatosensory evoked potentials showed non- significance among the two studied groups (P ≥ 0.05). External anal sphincter neuropathic affection was detected in 27 patients (71%) and external urethral sphincter neuropathic affection was detected in 30 patients (78.9%). The clitoral anal reflex showed the highest sensitivity and specificity among the neurophysiologic tests used in assessing the neuropathic affection (86.7 and 83%, respectively), followed by PNTML (83.3 and 80%, respectively). CONCLUSION: Pudendal neuropathy is the dominating possible attributing factor in the pathogenesis underlying idiopathic OAB. An integrated clinical, urodynamic, and electro-physiological assessment is recommended for evaluation of any overactive bladder patients.


Assuntos
Neuralgia do Pudendo/fisiopatologia , Reflexo Anormal/fisiologia , Bexiga Urinária Hiperativa/fisiopatologia , Adulto , Estudos Transversais , Eletromiografia , Feminino , Humanos , Pessoa de Meia-Idade , Nervo Pudendo/fisiopatologia , Neuralgia do Pudendo/complicações , Inquéritos e Questionários , Bexiga Urinária Hiperativa/etiologia , Urodinâmica/fisiologia , Adulto Jovem
8.
Neurourol Urodyn ; 38(1): 193-199, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30387531

RESUMO

BACKGROUND AND AIMS: Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. METHODS: Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. MAIN OUTCOME MEASURES: Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. RESULTS: 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. CONCLUSION: The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.


Assuntos
Canal Anal/lesões , Canal Anal/cirurgia , Parto Obstétrico/efeitos adversos , Incontinência Fecal/etiologia , Adulto , Canal Anal/fisiopatologia , Incontinência Fecal/diagnóstico por imagem , Feminino , Humanos , Manometria , Complicações do Trabalho de Parto , Forceps Obstétrico , Paridade , Gravidez , Estudos Prospectivos , Nervo Pudendo/fisiopatologia , Resultado do Tratamento , Ultrassonografia
9.
Am J Physiol Renal Physiol ; 315(6): F1555-F1564, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30132345

RESUMO

The pudendal nerve can be injured during vaginal delivery of children, and slowed pudendal nerve regeneration has been correlated with development of stress urinary incontinence (SUI). Simultaneous injury to the pudendal nerve and its target muscle, the external urethral sphincter (EUS), during delivery likely leads to slowed neuroregeneration. The goal of this study was to determine if repeat electrical stimulation of the pudendal nerve improves SUI recovery and promotes neuroregeneration in a dual muscle and nerve injury rat model of SUI. Rats received electrical stimulation or sham stimulation of the pudendal nerve twice weekly for up to 2 wk after injury. A separate cohort of rats received sham injury and sham stimulation. Expression of brain-derived neurotrophic factor (BDNF) and ßII-tubulin expression in Onuf's nucleus were measured 2, 7, and 14 days after injury. Urodynamics, leak point pressure (LPP), and EUS electromyography (EMG) were recorded 14 days after injury. Electrical stimulation significantly increased expression of BDNF at all time points and ßII-tubulin 1 and 2 wk after injury. Two weeks after injury, LPP and EUS EMG during voiding and LPP testing were significantly decreased compared with sham-injured animals. Electrical stimulation significantly increased EUS activity during voiding, although LPP did not fully recover. Repeat pudendal nerve stimulation promotes neuromuscular continence mechanism recovery possibly via a neuroregenerative response through BDNF upregulation in the pudendal motoneurons in this model of SUI. Electrical stimulation of the pudendal nerve may therefore improve recovery after childbirth and ameliorate symptoms of SUI by promoting neuroregeneration after injury.


Assuntos
Terapia por Estimulação Elétrica/métodos , Regeneração Nervosa , Traumatismos dos Nervos Periféricos/terapia , Nervo Pudendo/fisiopatologia , Bexiga Urinária/inervação , Incontinência Urinária por Estresse/terapia , Urodinâmica , Animais , Fator Neurotrófico Derivado do Encéfalo/metabolismo , Modelos Animais de Doenças , Feminino , Traumatismos dos Nervos Periféricos/metabolismo , Traumatismos dos Nervos Periféricos/fisiopatologia , Nervo Pudendo/lesões , Nervo Pudendo/metabolismo , Ratos Sprague-Dawley , Recuperação de Função Fisiológica , Tubulina (Proteína)/metabolismo , Bexiga Urinária/metabolismo , Incontinência Urinária por Estresse/metabolismo , Incontinência Urinária por Estresse/fisiopatologia
10.
Urology ; 116: 23-29, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29604315

RESUMO

OBJECTIVE: To examine the feasibility of implementing a standardized, clinically relevant genitourinary examination for both men and women, and to identify physical examination findings characteristic of urologic chronic pelvic pain syndrome (UCPPS). MATERIALS AND METHODS: This study analyzed 2 samples: men and women with UCPPS who participated in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network Epidemiology and Phenotyping (EP) Study, and age-matched controls who were either positive for chronic fatigue syndrome or healthy (pain-free). We compared physical examination findings in both positive and healthy controls with UCPPS cases: findings from both the EP examinations and from an extended genitourinary examination. RESULTS: EP and extended examinations were performed on 143 participants: 62 UCPPS cases (30 women, 32 men), 42 positive controls (15 women, 27 men), and 39 healthy controls (22 women, 17 men). EP examinations showed that pelvic floor tenderness was more prevalent in cases (55.0%) than in positive (14.6%) or healthy controls (10.5%). Extended examinations revealed specific areas of tenderness in the pelvic floor musculature. Cases were also more likely than healthy controls to report tenderness in multiple areas, including suprapubic, symphysis pubis, and posterior superior iliac spine, and on bimanual examination. No comparative findings were specific to biological sex, and no evidence of pudendal neuropathy was observed on extended examination of cases or controls. CONCLUSION: The extended genitourinary examination is an easily administered addition to the assessment of men and women during evaluation for UCPPS. Physical findings may help to better categorize patients with UCPPS into clinically relevant subgroups for optimal treatment.


Assuntos
Dor Crônica/diagnóstico , Dor Pélvica/diagnóstico , Exame Físico , Adulto , Algoritmos , Antropometria , Dor Crônica/etiologia , Estudos Transversais , Cistite/complicações , Cistite/diagnóstico , Síndrome de Fadiga Crônica , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Palpação , Distúrbios do Assoalho Pélvico/diagnóstico , Dor Pélvica/etiologia , Prostatite/complicações , Prostatite/diagnóstico , Nervo Pudendo/fisiopatologia , Reflexo Anormal
11.
Int J Colorectal Dis ; 33(3): 305-310, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29330765

RESUMO

PURPOSE: Pudendal nerve terminal motor latency (PNTML) testing is a standard recommendation for the evaluation of fecal incontinence. Its role in guiding therapy for fecal incontinence has been previously questioned. The aim of this study was to evaluate the relationship between PNTML testing and anorectal dysfunction. METHODS: This was a retrospective analysis of data collected prospectively from patients who presented to a pelvic floor disorder center from 2007 to 2015. The relationship between PNTML (normal versus delayed) and anorectal manometry, fecal incontinence severity, and fecal incontinence-related quality of life scores was assessed using the Wilcoxon-Mann-Whitney test. RESULTS: Two hundred sixty-nine patients underwent PNTML testing, and 91.1% were female (N = 245) (median age 62.2 years). Normal PNTML was seen in 234 (87.0%) patients. Among 268 patients who underwent anorectal manometry, delayed PNTML was only significantly associated with median maximum anal squeeze pressure (P = 0.04). Delayed PNTML was not associated with a decrease in median fecal incontinence severity or fecal incontinence-related quality of life scores (N = 99). CONCLUSIONS: PNTML was only associated with median maximum anal squeeze pressure, and it was not associated with patient-reported severity of symptoms of fecal incontinence, changes in quality of life attributable to fecal incontinence, median mean resting anal pressure, or median maximum resting anal pressure. PNTML testing may not be relevant to current therapeutic algorithms for fecal incontinence and its routine use should be questioned.


Assuntos
Incontinência Fecal/fisiopatologia , Incontinência Fecal/terapia , Atividade Motora , Nervo Pudendo/fisiopatologia , Tempo de Reação , Canal Anal/fisiopatologia , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Qualidade de Vida , Reto/fisiopatologia , Inquéritos e Questionários
12.
Am J Physiol Regul Integr Comp Physiol ; 314(1): R34-R42, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-28931549

RESUMO

This study tested the hypothesis that sacral neuromodulation, i.e., electrical stimulation of afferent axons in sacral spinal root, can block pudendal afferent inhibition of the micturition reflex. In α-chloralose-anesthetized cats, pudendal nerve stimulation (PNS) at 3-5 Hz was used to inhibit bladder reflex activity while the sacral S1 or S2 dorsal root was stimulated at 15-30 Hz to mimic sacral neuromodulation and to block the bladder inhibition induced by PNS. The intensity threshold (T) for PNS or S1/S2 dorsal root stimulation (DRS) to induce muscle twitch of anal sphincter or toe was determined. PNS at 1.5-2T intensity inhibited the micturition reflex by significantly ( P < 0.01) increasing bladder capacity to 150-170% of control capacity. S1 DRS alone at 1-1.5T intensity did not inhibit bladder activity but completely blocked PNS inhibition and restored bladder capacity to control level. At higher intensity (1.5-2T), S1 DRS alone inhibited the micturition reflex and significantly increased bladder capacity to 135.8 ± 6.6% of control capacity. However, the same higher intensity S1 DRS applied simultaneously with PNS, suppressed PNS inhibition and significantly ( P < 0.01) reduced bladder capacity to 126.8 ± 9.7% of control capacity. S2 DRS at both low (1T) and high (1.5-2T) intensity failed to significantly reduce PNS inhibition. PNS and S1 DRS did not change the amplitude and duration of micturition reflex contractions, but S2 DRS at 1.5-2T intensity doubled the duration of the contractions and increased bladder capacity. These results are important for understanding the mechanisms underlying sacral neuromodulation of nonobstructive urinary retention in Fowler's syndrome.


Assuntos
Plexo Lombossacral , Inibição Neural , Nervo Pudendo/fisiopatologia , Reflexo , Estimulação Elétrica Nervosa Transcutânea/métodos , Bexiga Urinária/inervação , Retenção Urinária/terapia , Micção , Animais , Gatos , Modelos Animais de Doenças , Feminino , Masculino , Diafragma da Pelve/inervação , Síndrome , Uretra/inervação , Retenção Urinária/etiologia , Retenção Urinária/fisiopatologia , Urodinâmica
13.
Neurourol Urodyn ; 37(1): 27-32, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28419532

RESUMO

AIM: To present the teaching module "Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults." This teaching module embodies a presentation, in combination with this manuscript. This manuscript serves as a scientific background review; the evidence base made available on ICS website to summarize current knowledge and recommendations. METHODS: This review has been prepared by a Working Group of The ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel. RESULTS: Electromyography (EMG) is a method to record spontaneous or artificially induced electrical activity of the nerve-muscle unit or to test nerve conductivity. EMG of the anal sphincter using surface electrode is most widely used screening technique to detect detrusor-sphincter dyssynergia in urology. It is non-invasive and easy to perform. EMG methods using needle electrodes are reserved for diagnostics in well selected group of mainly neurogenic patients. These methods require expertise in the field of general EMG and are usually performed by neurologist and neuro-physiologist. The evidence in many aspects of use of EMG in urology remains sparse. CONCLUSIONS: Currently EMG methods rarely play a decision making role in selecting proper treatment of lower urinary tract dysfunction. With the current efforts to improve phenotyping of these patients in order to provide individualized treatment, the role of EMG could increase.


Assuntos
Eletromiografia/métodos , Sintomas do Trato Urinário Inferior/diagnóstico , Sintomas do Trato Urinário Inferior/terapia , Distúrbios do Assoalho Pélvico/diagnóstico , Distúrbios do Assoalho Pélvico/terapia , Canal Anal/fisiopatologia , Biorretroalimentação Psicológica , Eletrodos , Eletromiografia/instrumentação , Humanos , Sintomas do Trato Urinário Inferior/etiologia , Sintomas do Trato Urinário Inferior/fisiopatologia , Distúrbios do Assoalho Pélvico/etiologia , Distúrbios do Assoalho Pélvico/fisiopatologia , Nervo Pudendo/fisiopatologia , Uretra/fisiopatologia , Urodinâmica/fisiologia
14.
Acta Radiol ; 59(8): 932-938, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29065701

RESUMO

Background Identification of the source of postpartum hemorrhage (PPH) is important for embolization because PPH frequently originates from non-uterine arteries. Purpose To evaluate the clinical importance of identifying the non-uterine arteries causing the PPH and the results of their selective embolization. Material and Methods This retrospective study enrolled 59 patients who underwent embolization for PPH from June 2009 to July 2016. Angiographic findings and medical records were reviewed to determine whether non-uterine arteries contributed to PPH. Arteries showing extravasation or hypertrophy accompanying uterine hypervascular staining were regarded as sources of the PPH. The results of their embolization were analyzed. Results Of 59 patients, 19 (32.2%) underwent embolization of non-uterine arteries. These arteries were ovarian (n = 7), vaginal (n = 5), round ligament (n = 5), inferior epigastric (n = 3), cervical (n = 2), internal pudendal (n = 2), vesical (n = 1), and rectal (n = 1) arteries. The embolic materials used included n-butyl cyanoacrylate (n = 9), gelatin sponge particles (n = 8), gelatin sponge particles with microcoils (n = 1), and polyvinyl alcohol particles (n = 1). In 13 patients, bilateral uterine arterial embolization was performed. Re-embolization was performed in two patients with persistent bleeding. Hemostasis was achieved in 17 (89.5%) patients. Two patients underwent immediate hysterectomy due to persistent bleeding. One patient experienced a major complication due to pelvic organ ischemia. One patient underwent delayed hysterectomy for uterine infarction four months later. Conclusion Non-uterine arteries are major sources of PPH. Detection and selective embolization are important for successful hemostasis.


Assuntos
Embolização Terapêutica/métodos , Hemorragia Pós-Parto/terapia , Adulto , Angiografia , Artérias Epigástricas/diagnóstico por imagem , Artérias Epigástricas/fisiopatologia , Feminino , Genitália Feminina/irrigação sanguínea , Genitália Feminina/diagnóstico por imagem , Genitália Feminina/fisiopatologia , Humanos , Hemorragia Pós-Parto/diagnóstico por imagem , Nervo Pudendo/irrigação sanguínea , Nervo Pudendo/diagnóstico por imagem , Nervo Pudendo/fisiopatologia , Reto/irrigação sanguínea , Reto/diagnóstico por imagem , Reto/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Bexiga Urinária/irrigação sanguínea , Bexiga Urinária/diagnóstico por imagem , Bexiga Urinária/fisiopatologia , Adulto Jovem
15.
Am J Physiol Renal Physiol ; 314(4): F543-F550, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29141938

RESUMO

Pudendal nerve stimulation is a promising treatment approach for lower urinary tract dysfunction, including symptoms of overactive bladder. Despite some promising clinical studies, there remain many unknowns as to how best to stimulate the pudendal nerve to maximize therapeutic efficacy. We quantified changes in bladder capacity and voiding efficiency during single-fill cystometry in response to electrical stimulation of the sensory branch of the pudendal nerve in urethane-anesthetized female Wistar rats. Increases in bladder capacity were dependent on both stimulation amplitude and rate. Stimulation that produced increases in bladder capacity also led to reductions in voiding efficiency. Also, there was a stimulation carryover effect, and increases in bladder capacity persisted during several nonstimulated trials following stimulated trials. Intravesically administered PGE2 reduced bladder capacity, producing a model of overactive bladder (OAB), and sensory pudendal nerve stimulation again increased bladder capacity but also reduced voiding efficiency. This study serves as a basis for future studies that seek to maximize the therapeutic efficacy of sensory pudendal nerve stimulation for the symptoms of OAB.


Assuntos
Terapia por Estimulação Elétrica/métodos , Nervo Pudendo/fisiopatologia , Bexiga Urinária Hiperativa/terapia , Bexiga Urinária/inervação , Urodinâmica , Animais , Dinoprostona , Modelos Animais de Doenças , Feminino , Ratos Wistar , Bexiga Urinária Hiperativa/induzido quimicamente , Bexiga Urinária Hiperativa/fisiopatologia
16.
Scand J Urol ; 51(5): 414-419, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28678646

RESUMO

OBJECTIVE: A thorough clinical assessment including physical examination is crucial in a diagnostic work-up, including in patients with chronic pelvic pain syndrome (CPPS). This study investigated the prevalence of pain areas and the mechanosensitivity of peripheral nerves in patients with CPPS and compared the findings with a healthy control group. MATERIALS AND METHODS: Healthy volunteers and patients diagnosed with CPPS were assessed with physical examinations and neurodynamic testing. RESULTS: The CPPS group (n = 26) and the control group (n = 28) showed no statistical differences between males and females for age and body mass index (Mann-Whitney U test). The patients in the CPPS group were significantly older and had a significantly higher weight compared to controls. Healthy volunteers did not show any pain area or mechanosensitivity of the examined peripheral nerves of the lumbosacral plexus. Patients with CPPS showed a variety of pain from different musculoskeletal origins. Neurodynamic testing demonstrated significant mechanosensitivity in at least one nerve of the lumbosacral plexus in 88% of the patients with CPPS, suggesting minor nerve injuries. Pudendal nerve mechanosensitivity was found in 85% of patients, while 42% had multiple nerves involved. Unilateral or bilateral pudendal channel palpatory pain was present in 62% of the CPPS group and not in controls. CONCLUSIONS: This study shows musculoskeletal pain and a high prevalence of minor nerve injuries in CPPS patients, indicating the presence of abnormal impulse generation sites that can help in understanding the clinical picture in CPPS patients and guiding their treatment.


Assuntos
Dor Crônica/fisiopatologia , Plexo Lombossacral/fisiopatologia , Dor Musculoesquelética/fisiopatologia , Dor Pélvica/fisiopatologia , Dor Abdominal/fisiopatologia , Adulto , Estudos de Casos e Controles , Dor Crônica/etiologia , Feminino , Humanos , Plexo Lombossacral/lesões , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/etiologia , Palpação/efeitos adversos , Dor Pélvica/etiologia , Exame Físico , Nervo Pudendo/fisiopatologia , Estresse Mecânico , Síndrome , Adulto Jovem
17.
Am J Physiol Renal Physiol ; 313(3): F815-F825, 2017 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28637788

RESUMO

Obesity is a global epidemic associated with an increased risk for lower urinary tract dysfunction. Inefficient voiding and urinary retention may arise in late-stage obesity when the expulsive force of the detrusor smooth muscle cannot overcome outlet resistance. Detrusor underactivity (DUA) and impaired contractility may contribute to the pathogenesis of nonobstructive urinary retention. We used cystometry and electrical stimulation of peripheral nerves (pudendal and pelvic nerves) to characterize and improve bladder function in urethane-anesthetized obese-prone (OP) and obese-resistant (OR) rats following diet-induced obesity (DIO). OP rats exhibited urinary retention and impaired detrusor contractility following DIO, reflected as increased volume threshold, decreased peak micturition pressure, and decreased voiding efficiency (VE) compared with OR rats. Electrical stimulation of the sensory branch of the pudendal nerve did not increase VE, whereas patterned bursting stimulation of the motor branch of the pudendal nerve increased VE twofold in OP rats. OP rats required increased amplitude of electrical stimulation of the pelvic nerve to elicit bladder contractions, and maximum evoked bladder contraction amplitudes were decreased relative to OR rats. Collectively, these studies characterize a novel animal model of DUA that can be used to determine pathophysiology and suggest that neuromodulation is a potential management option for DUA.


Assuntos
Terapia por Estimulação Elétrica/métodos , Plexo Hipogástrico/fisiopatologia , Músculo Liso/inervação , Obesidade/complicações , Nervo Pudendo/fisiopatologia , Bexiga Urinária/inervação , Retenção Urinária/terapia , Micção , Animais , Dieta Hiperlipídica , Modelos Animais de Doenças , Feminino , Contração Muscular , Retenção Urinária/etiologia , Retenção Urinária/fisiopatologia , Urodinâmica
19.
J Pharmacol Exp Ther ; 362(1): 53-58, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28428223

RESUMO

The involvement of ionotropic glutamate receptors in bladder overactivity and pudendal neuromodulation was determined in α-chloralose anesthetized cats by intravenously administering MK801 (a NMDA receptor antagonist) or CP465022 (an AMPA receptor antagonist). Infusion of 0.5% acetic acid (AA) into the bladder produced bladder overactivity. In the first group of 5 cats, bladder capacity was significantly (P < 0.05) reduced to 55.3±10.0% of saline control by AA irritation. Pudendal nerve stimulation (PNS) significantly (P < 0.05) increased bladder capacity to 106.8 ± 15.0% and 106.7 ± 13.3% of saline control at 2T and 4T intensity, respectively. T is threshold intensity for inducing anal twitching. MK801 at 0.3 mg/kg prevented the increase in capacity by 2T or 4T PNS. In the second group of 5 cats, bladder capacity was significantly (P < 0.05) reduced to 49.0 ± 7.5% of saline control by AA irritation. It was then significantly (P < 0.05) increased to 80.8±13.5% and 79.0±14.0% of saline control by 2T and 4T PNS, respectively. CP465022 at 0.03-1 mg/kg prevented the increase in capacity by 2T PNS and at 0.3-1 mg/kg prevented the increase in capacity by 4T PNS. In both groups, MK801 at 0.3 mg/kg and CP465022 at 1 mg/kg significantly (P < 0.05) increased the prestimulation bladder capacity (about 80% and 20%, respectively) and reduced the amplitude of bladder contractions (about 30 and 20 cmH2O, respectively). These results indicate that NMDA and AMPA glutamate receptors are important for PNS to inhibit bladder overactivity and that tonic activation of these receptors also contributes to the bladder overactivity induced by AA irritation.


Assuntos
Antagonistas de Aminoácidos Excitatórios/uso terapêutico , Glutamatos , Nervo Pudendo/fisiopatologia , Bexiga Urinária Hiperativa/fisiopatologia , Ácido Acético , Animais , Gatos , Maleato de Dizocilpina/uso terapêutico , Relação Dose-Resposta a Droga , Estimulação Elétrica , Feminino , Masculino , Quinazolinas/uso terapêutico , Receptores de AMPA/antagonistas & inibidores , Receptores de N-Metil-D-Aspartato/antagonistas & inibidores , Bexiga Urinária/fisiopatologia , Bexiga Urinária Hiperativa/induzido quimicamente
20.
J Steroid Biochem Mol Biol ; 171: 229-235, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28408350

RESUMO

Recent reports show that, in patients treated with finasteride for male pattern hair loss, persistent side effects including sexual side effects, depression, anxiety and cognitive complaints may occur. We here explored the psychiatric and andrological features of patients affected by post-finasteride syndrome (PFS) and verified whether the cerebrospinal fluid (CSF) and plasma levels of neuroactive steroids (i.e., important regulators of nervous function) are modified. We found that eight out of sixteen PFS male patients considered suffered from a DSM-IV major depressive disorder (MDD). In addition, all PFS patients showed erectile dysfunction (ED); in particular, ten patients showed a severe and six a mild-moderate ED. We also reported abnormal somatosensory evoked potentials of the pudendal nerve in PFS patients with severe ED, the first objective evidence of a neuropathy involving peripheral neurogenic control of erection. Testicular volume by ultrasonography was normal in PFS patients. Data obtained on neuroactive steroid levels also indicate interesting features. Indeed, decreased levels of pregnenolone, progesterone and its metabolite (i.e., dihydroprogesterone), dihydrotestosterone and 17beta-estradiol and increased levels of dehydroepiandrosterone, testosterone and 5alpha-androstane-3alpha,17beta-diol were observed in CSF of PFS patients. Neuroactive steroid levels were also altered in plasma of PFS patients, however these changes did not reflect exactly what occurs in CSF. Finally, finasteride did not only affect, as expected, the levels of 5alpha-reduced metabolites of progesterone and testosterone, but also the further metabolites and precursors suggesting that this drug has broad consequence on neuroactive steroid levels of PFS patients.


Assuntos
Inibidores de 5-alfa Redutase/efeitos adversos , Transtorno Depressivo Maior/induzido quimicamente , Disfunção Erétil/induzido quimicamente , Finasterida/efeitos adversos , Pregnenolona/líquido cefalorraquidiano , Progesterona/líquido cefalorraquidiano , Testosterona/líquido cefalorraquidiano , Inibidores de 5-alfa Redutase/uso terapêutico , Adulto , Alopecia/tratamento farmacológico , Estudos de Casos e Controles , Transtorno Depressivo Maior/sangue , Transtorno Depressivo Maior/líquido cefalorraquidiano , Transtorno Depressivo Maior/epidemiologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Monitoramento de Medicamentos , Disfunção Erétil/epidemiologia , Disfunção Erétil/metabolismo , Disfunção Erétil/fisiopatologia , Potenciais Somatossensoriais Evocados/efeitos dos fármacos , Finasterida/uso terapêutico , Humanos , Incidência , Itália/epidemiologia , Estudos Longitudinais , Masculino , Pregnenolona/sangue , Progesterona/análogos & derivados , Progesterona/sangue , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Nervo Pudendo/efeitos dos fármacos , Nervo Pudendo/fisiopatologia , Neuralgia do Pudendo/induzido quimicamente , Neuralgia do Pudendo/epidemiologia , Neuralgia do Pudendo/metabolismo , Neuralgia do Pudendo/fisiopatologia , Índice de Gravidade de Doença , Testosterona/análogos & derivados , Testosterona/sangue , Adulto Jovem
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