Female sexuality in multiple sclerosis: the multidimensional nature of the problem and the intervention.

Female sexual functioning is a complex process involving physiological, psychosocial and interpersonal factors. Sexual dysfunction (SD) is frequent (40-74%) among women with multiple sclerosis (MS), reflecting neurological dysfunction, psychological factors, depression, side effects of medications and physical manifestations of the disease, such as fatigue and muscle weakness. A conceptual model for sexual problems in MS characterizes three levels. Primary SD includes impaired libido, lubrication, and orgasm. Secondary SD is composed of limiting sexual expressions due to physical manifestations. Tertiary SD results from psychological, emotional, social, and cultural aspects. Sexual problems cause distress and may affect the family bond. Practical suggestions on initiation of discussion of sexual issues for MS patients are included in this review. Assessment and treatment of sexual problems should combine medical and psychosexual approaches and begin early after MS diagnosis. Intervention can be done by recognizing sexual needs, educating and providing information, by letting patients express their difficulties and referring them to specialists and other information resources.

Diffusional Kurtosis along the Corticospinal Tract in Adult Normal Pressure Hydrocephalus.

BACKGROUND AND PURPOSE: Normal Pressure Hydrocephalus is a reversible form of dementia characterized by enlarged ventricles, which can deform and cause disruptions to adjacent white matter fibers. The purpose of this work was to examine how diffusion and kurtosis parameters vary along the corticospinal tract and determine where along this path microstructure is compromised in patients diagnosed with normal pressure hydrocephalus. We hypothesized that disruption of the corticospinal tract from ventricular enlargement can be measured using diffusion MR imaging and this will be quantified in periventricular regions. MATERIALS AND METHODS: We developed a method to analyze diffusion parameters at discrete points along neural tracts. We then used diffusion MR imaging data from patients with Alzheimer disease and healthy controls to compare whether diffusion along the corticospinal tract differs from that of patients with normal pressure hydrocephalus. RESULTS: We found that diffusion parameters can differentiate patients with normal pressure hydrocephalus from those with Alzheimer disease and healthy controls: Axial diffusion, axial kurtosis, and the axonal water fraction were found to differ significantly across groups (P < .05) in an area located close to the superior internal capsule and corona radiata but below the cortex. CONCLUSIONS: A lower axonal water fraction indicates a lower axonal density in the corticospinal tract, which may indicate permanent damage. Lower axial kurtosis may imply that axons are being more aligned due to compression.

Comorbid Normal Pressure Hydrocephalus with Parkinsonism: A Clinical Challenge and Call for Awareness.

Idiopathic normal pressure hydrocephalus (iNPH) is the most common cause of hydrocephalus in adults. The diagnosis may be challenging, requiring collaborative efforts between different specialists. According to the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders, iNPH should be considered in the differential of any unexplained gait failure with insidious onset. Recognizing iNPH can be even more difficult in the presence of comorbid neurologic disorders. Among these, idiopathic Parkinson's disease (PD) is one of the major neurologic causes of gait dysfunction in the elderly. Both conditions have their peak prevalence between the 6th and the 7th decade. Importantly, postural instability and gait dysfunction are core clinical features in both iNPH and PD. Therefore, diagnosing iNPH where diagnostic criteria of PD have been met represents an additional clinical challenge. Here, we report a patient with parkinsonism initially consistent with PD who subsequently displayed rapidly progressive postural instability and gait dysfunction leading to the diagnosis of concomitant iNPH. In the following sections, we will review the clinical features of iNPH, as well as the overlapping and discriminating features when degenerative parkinsonism is in the differential diagnosis. Understanding and recognizing the potential for concomitant disease are critical when treating both conditions.

Lumbar Puncture Test in Normal Pressure Hydrocephalus: Does the Volume of CSF Removed Affect the Response to Tap?

BACKGROUND AND PURPOSE: There is limited evidence to support the use of high-volume lumbar taps over lower-volume taps in the diagnosis of normal pressure hydrocephalus. The purpose of this study is to detect whether the volume of CSF removed from patients undergoing high-volume diagnostic lumbar tap test for normal pressure hydrocephalus is significantly associated with post-lumbar tap gait performance. MATERIALS AND METHODS: This retrospective study included 249 consecutive patients who underwent evaluation for normal pressure hydrocephalus. The patients were analyzed both in their entirety and as subgroups that showed robust response to the lumbar tap test. The volume of CSF removed was treated as both a continuous variable and a discrete variable. Statistical tests were repeated with log-normalized volumes. RESULTS: This study found no evidence of a relationship between the volume of CSF removed during the lumbar tap test and subsequent gait test performance in the patient population (Pearson coefficient r = 0.049-0.129). Log normalization of the volume of CSF removed and controlling for age and sex failed to yield a significant relationship. Subgroup analyses focusing on patients who showed greater than 20% improvement in any of the gait end points or who were deemed sufficiently responsive clinically to warrant surgery also yielded no significant relationships between the volume of CSF removed and gait outcomes, but there were preliminary findings that patients who underwent tap with larger-gauge needles had better postprocedure ambulation among patients who showed greater than 20% improvement in immediate time score (P = .04, n = 62). CONCLUSIONS: We found no evidence to support that a higher volume of CSF removal impacts gait testing, suggesting that a high volume of CSF removal may not be necessary in a diagnostic lumbar tap test.

Cortisol reduces hippocampal glucose metabolism in normal elderly, but not in Alzheimer's disease.

Glucocorticoids are known to play a role in the regulation of peripheral glucose mobilization and metabolism. Although several animal studies have shown that hippocampal glucose metabolism is reduced acutely and chronically by the action of corticosterone and that excess glucocorticoids are harmful to hippocampal neurons, little is known about the central effects of glucocorticoids in the human. In this study we examined the brain glucose utilization (CMRglu) response to hydrocortisone (cortisol) in seven normal elderly and eight Alzheimer's disease (AD) patients. On 2 separate days, immediately after the administration of a bolus of either 35 mg hydrocortisone or placebo, we administered 2-deoxy-2-[18F]fluoro-D-glucose. After a 35-min radiotracer uptake period, positron emission tomography (PET) images were collected. PET CMRglu images were analyzed using two methods: an image transformation that allowed analyses across cases on a voxel by voxel basis, and an anatomically based region of interest method that used coregistered magnetic resonance imaging scans. Both image analysis methods yielded similar results, identifying relative to placebo, a specific hippocampal CMRglu reduction in response to the hydrocortisone challenge that was restricted to the normal group. The region of interest technique showed CMRglu reductions of 16% and 12% in the right and left hippocampi, respectively. Blood collected during the PET scans showed, for the normal group, a rise in plasma glucose levels, starting approximately 25 min after hydrocortisone administration. The AD group did not show this effect. Baseline cortisol was elevated in the AD group, but the clearance of hydrocortisone was not different between the groups. In conclusion, these data show that among normal individuals in the presence of a pharmacological dose of cortisol, the glucose utilization of the hippocampus is specifically reduced, and serum glucose levels increase. Based in part on other studies, we offer the interpretation that glucocorticoid-mediated regulation of glucose transport is altered in AD, and this may underlie both the hippocampal insensitivity to cortisol and the failure in these patients to mount a peripheral glucose response. As our findings could reflect an altered state of the AD patients, we interpret our results as preliminary with respect to evidence for metabolic abnormalities in AD. The results suggest the continued study of the hydrocortisone challenge as a test of hippocampal responsivity.

Frequency of hippocampal formation atrophy in normal aging and Alzheimer's disease.

We used CT and MR to examine the frequency of occurrence of hippocampal formation atrophy (HA) in a research clinic population of 130 normal elderly, 72 nondemented patients with very mild memory and cognitive impairments (MCI), 73 mild Alzheimer's disease (AD) patients, and 130 patients with moderate to severe AD. HA was found in 29% of the normal elderly group and its frequency of occurrence was strongly related to increasing age. For normal elderly 60-75 years of age, 15% had HA: the proportion rose to 48% in subjects 76-90 years of age. Among the three groups of impaired patients, the frequencies of HA ranged from 78% in the MCI patients to 96% in the advanced AD group. Unlike the normal elderly group, the percentages were not related to age. In both the normal elderly group and MCI group disproportionately more males than females had HA. After controlling for learning and the effects of generalized brain changes as reflected in ventricular size, only in the normal group was HA associated with reduced delayed verbal recall performance. Follow-up examinations for 15 individuals with baseline HA. 4 who at entry were MCI and 11 probable AD, yielded clinical and neuropathologic diagnoses of AD in all cases. The results of the present study indicate that hippocampal formation atrophy is associated with memory and cognitive impairments. Further longitudinal and neuropathologic work is required to validate the relationship between hippocampal formation atrophy and AD.

Hippocampal atrophy in normal aging. An association with recent memory impairment.

OBJECTIVE: To estimate the prevalence of radiographically detectable hippocampal atrophy (HA) in a normal aging sample and to test whether such atrophy is associated with memory dysfunction. DESIGN: One hundred fifty-four medically healthy and cognitively normal elderly persons (aged 55 to 88 years) received magnetic resonance imaging and/or computed tomographic scans designed to identify HA. One hundred forty-five of these subjects also underwent psychometric tests of memory function. Multivariate analyses of variance were used to evaluate differences in memory performance between subjects with and without HA. SETTING: This study was conducted at a research clinic for the investigation of age-associated neuropsychological and neuroradiologic changes. PARTICIPANTS: Based on the following criteria, 154 subjects were consecutively selected from a larger group of elderly research volunteers participating in a study of normal aging: age of 55 years or greater; Global Deterioration Scale score of 2 or less; and Mini-Mental State examination score of 28 or greater. Subjects with evidence for significant medical, psychiatric, or neurologic disease were excluded. MAIN OUTCOME MEASURES: Outcome measurements included individual psychometric test scores and computed tomographic-magnetic resonance imaging hippocampal atrophy ratings. RESULTS: Nearly 33% of the subjects had radiographic evidence for HA. The prevalence of HA increased significantly with age and was more common in male than female subjects. After controlling for age, level of education, and vocabulary, subjects with HA were found to perform more poorly on tests of recent (secondary) verbal memory when compared with subjects without HA (P < .01). No significant differences were found for tests of immediate (primary) memory. CONCLUSION: We conclude that HA is a common accompaniment of normal aging and is associated with mild memory impairment. Additional research is needed to determine whether HA constitutes a significant risk for future dementia.

Topography of cross-sectional and longitudinal glucose metabolic deficits in Alzheimer's disease. Pathophysiologic implications.

Positron emission tomographic studies of cerebral glucose metabolism have shown high diagnostic specificity in distinguishing among the degenerative dementias and differentiating between Alzheimer's disease (AD) and normal aging. The current investigation was undertaken to characterize the regional glucose metabolic deficits in AD, using cross-sectional and longitudinal study designs. All subjects met the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for AD (n = 45) or were normal (n = 20), and the AD subjects were subdivided into incipient and mild AD and moderate plus moderately severe subgroups based on the Global Deterioration Scale. The subjects underwent a non-contrast computed tomographic scan and a positron emission tomographic (PETT VI) scan. The AD subjects (n = 14) and normal control subjects (n = 15) received evaluations 2 to 3 years after baseline study. The brain regions that show glucose metabolic deficits cross-sectionally (temporal and parietal association areas, with lesser degrees of deficit in subcortical gray matter structures), over the stages of AD, also show further deficits longitudinally within the same AD subjects. The reduction in glucose metabolism is greater than would be expected from the degree of brain atrophy. The glucose metabolic deficits are discussed in the context of neuropathologic findings and neurotransmitter deficits in AD.

Hippocampal formation size predicts declining memory performance in normal aging.

Hippocampal formation (HF) atrophy, although common in normal aging, has unknown clinical consequences. We used MRI to derive HF size measurements at baseline on 44 cognitively normal older adults entering a longitudinal study of memory function (mean age = 68.4 years, mean follow-up = 3.8 years). Only one subject became demented at follow-up. Multiple regression analyses controlling for age, gender, education, and diffuse cerebral atrophy revealed that HF size significantly predicted longitudinal change on memory tests previously found sensitive to decline in normal aging. These results indicate HF atrophy may be a risk factor for accelerated memory dysfunction in normal aging.

In vivo structural studies of the hippocampus in normal aging and in incipient Alzheimer's disease.

Population trends indicate that in the near future the size of the elderly population will increase. This will result in a large increment in the numbers of persons suffering mild to severe levels of cognitive impairment. While considerable efforts continue to be made to explain brain changes associated with Alzheimer disease (AD), little is known of the brain changes in aging without dementia or so-called normal aging. Pathologic studies suggest that the medial temporal lobe is informative in the examination of the early brain changes related to AD. However, pathologic studies only offer a single observation and considerable uncertainty exists regarding the likelihood of progression of disease and the development of dementia. Several structural neuroimaging studies have recently investigated this anatomy and recent reports are encouraging for a medial temporal lobe based diagnosis for age-related cognitive impairments. We will present our findings on the MRI anatomy of the hippocampal formation as well as data bearing on the use of hippocampal formation imaging in the diagnosis of AD and as a predictive marker for future dementia. Our findings suggest an anatomically specific relationship between hippocampal volume and secondary memory performance. Because these observations apply to nondemented and normal elderly subjects, we are encouraged that the anatomy of age-related cognitive impairments can be reliably recognized and possibly put to use in therapeutic studies.

Basal cell hyperplasia of prostate: an elusive lesion?

We report a case of basal cell hyperplasia of the prostate accompanying benign prostatic hypertrophy. The histogenesis of the basal cells as well as the histologic features and differential diagnosis of basal cell hyperplasia are reviewed.

Raz bladder neck suspension in women younger than sixty-five years compared with elderly women: three years' experience.

OBJECTIVE: To verify the efficacy of Raz bladder neck suspension in producing cure of genuine stress incontinence (GSI) in women younger than sixty-five years compared with elderly women, and to find out whether or not elderly patients are more prone to failure with this technique. METHOD: We reviewed our results with this procedure in 67 women younger than sixty-five years (group I) compared with 21 elderly women (group II). Seventeen patients in group I and 4 patients in group II had bladder neck suspension for grade I-II incontinence, and 50 patients in group I and 17 in group II had additional cystocele repair by the four-corner technique. Rectocele repair and vaginal hysterectomy were also performed when indicated. RESULTS: With a mean follow-up period of 18.2 months for group I and 16.8 months for group II, 57 women (85.1%) in group I were completely cured of stress incontinence, 6 (8.9%) had marked improvement, and 4 (6.0%) had recurrence, while in group II, 19 (90.4%) were completely cured, 1 (4.8%) had marked improvement, and 1 (4.8%) had recurrence. Namely, in group I, 94 percent of the patients were either cured or improved, as compared with 95.2 percent in group II (P = 0.6; Fisher's exact test). Postoperative complications were few, and there was no permanent urinary retention. CONCLUSION: We conclude that, in a relatively short-term follow-up, Raz bladder neck suspension is equally successful in curing stress urinary incontinence in young and elderly females.

Extended double-J ureteral stent.

Continent forms of urinary diversion using intestinal segments are becoming increasingly common. As this new treatment modality evolves, our instruments and mechanical devices are likewise evolving and adapting to the changing needs placed on them. We have used a new type of double-pigtail ureteral catheter in patients requiring continent urinary diversion. It allows stenting of the ureteral-intestinal anastomosis and safeguards against urinary leak or extravasation; at the same time the catheter is accessible to the outside for easy replacement, manipulation, and radiographic evaluation. The catheter has also shown to be useful for other purposes such as uretero-neo-cystostomy. This is particularly important in the pediatric population where repeated cystoscopy for stent removal or manipulation can be a significant drawback.

Kidney stone formed around refluxed surgical staple and removed by transureteral endoscopic manipulation.

We present a case of a kidney stone that developed around a surgical staple which refluxed up to the kidney following a Bricker urinary diversion and bilateral ureteroileal anastomosis. A GIA stapler had been utilized to construct the ileal conduit. The stone was retrieved by means of flexible ureterorenoscopy through the ileal conduit. To our knowledge, this is the first report of such a complication following construction of an ileal conduit with a stapling device.

Effects of prostatectomy on sexual function.

We evaluated the effects of prostatectomy on sexual function in 210 patients, 49.6 percent of whom underwent transurethral resection of the prostate (TURP), and the remainder had suprapubic transvesical prostatectomy (SPP). Pre- and postoperative interviews with detailed questionnaires were utilized. Postoperative sexual dysfunction was reported by 18 of 152 patients (11.8%) who were functioning normally prior to surgery. The incidence of postoperative impotence was evenly distributed between the TURP and SPP groups and was age-related; it was highest among older patients. We further observed a strong correlation between the presence of a permanent sexual partner and the preservation of potency. We conclude that the risk of postoperative impotence is dependent on both the patient's age and the presence of a partner, and should be discussed with the patient preoperatively.

Demonstration of antispermatozoal antibodies in varicocele-related infertility with an enzyme-linked immunosorbent assay (ELISA).

To assess the existence of a possible immunologic factor in varicocele-associated infertility, we searched for antispermatozoal antibodies in serum, seminal plasma, and bound to spermatozoa in 32 infertile men with varicocele and 22 infertile patients without palpable varicocele, with the use of an enzyme-linked immunosorbent assay. In addition, we performed morphologic and microbiologic analyses of the semen and urethral smears for isolation of Chlamydia trachomatis. Twenty-nine men from the varicocele group (90.6%) demonstrated antispermatozoal antibodies, compared with only 9 men (40.9%) in the control group. The antibodies in both groups, when present, were mainly serum and seminal plasma immunoglobulins IgA and IgM. A significant quantitative difference between the varicocele and control groups was also observed for serum IgA, seminal plasma IgA and IgM, and sperm-bound IgG, IgA, and IgM. Oligozoospermia and asthenozoospermia were significantly more prevalent in the varicocele men. An asymptomatic genital tract infection with C. trachomatis, Ureaplasma urealyticum, and Escherichia coli was traced in 40.6% of the varicocele men and in 45.5% of the control group. No interaction could be demonstrated between the infection and antispermatozoal antibody formation. These data suggest that an immunologic factor may play a role in varicocele-associated infertility; however, its impact on reproduction has yet to be assessed.

The radiologic prediction of Alzheimer disease: the atrophic hippocampal formation.

PURPOSE: To test the hypothesis that atrophy of the hippocampal formation in nondemented elderly individuals would predict subsequent Alzheimer disease. METHOD: We studied 86 subjects at two time points, 4 years apart. At baseline all study subjects were nondemented and included 54 control subjects and 32 persons who had memory complaints and minimal cognitive impairments. All subjects received a CT scan using a protocol designed to image the perihippocampal cerebrospinal fluid (HCSF) accumulating in the fissures along the axis of the hippocampal formation. Blind to the clinical evaluations, we subjectively assessed the presence of HCSF at the baseline. Retrospectively, we examined the predicted association between baseline HCSF and clinical decline as determined across the two evaluations. RESULTS: At follow-up 25 of the 86 subjects had deteriorated and received the diagnosis of Alzheimer disease. Of the declining subjects, 23 came from the minimally impaired group, and 2 came from the control group. In the minimally impaired group the baseline HCSF measure had a sensitivity of 91% and a specificity of 89% as a predictor of decline. Both control subjects who deteriorated were also correctly identified at baseline. One of these two subjects died, and an autopsy confirmed the presence of Alzheimer disease. M(r) validation studies demonstrated that HCSF is quantitatively related to dilatation of the transverse fissure of Bichat and the choroidal and hippocampal fissures. CONCLUSION: Our findings strongly suggest that among persons with mild memory impairments, dilatation of the perihippocampal fissures is a useful radiologic marker for identifying the early features of Alzheimer disease.

Focal dilation and paradoxical collapse of cortical fissures and sulci in patients with normal-pressure hydrocephalus.

OBJECT: The authors describe a subgroup of patients with shunt-proven normal-pressure hydrocephalus (NPH) who presented with focal fissural and sulcal dilation on imaging studies. The specific radiological features and methods of differentiating this condition from cortical atrophy are delineated. METHODS: Normal-pressure hydrocephalus has been described as dilation of the ventricles that is out of proportion to the sulci. Sulcal dilation has been taken as evidence of cortical atrophy and has even been used as a criterion to exclude patients from undergoing a shunting procedure. The authors describe five cases of patients with shunt-proven NPH who presented with focal dilation of cortical fissures and sulci. In three of the cases, there was a paradoxical decrease in the size of the dilated fissures and sulci that paralleled the decrease in the size of the lateral ventricles following successful shunting. CONCLUSIONS: This study demonstrates that focal fissural and sulcal dilation may represent reservoirs of cerebrospinal fluid analogous to the ventricular system. Patients should not be denied a shunting procedure solely on the basis of focally dilated fissures of sulci.

Neuropsychological prediction of decline to dementia in nondemented elderly.

This study examined whether baseline neuropsychological performance in elderly assessed at a research clinic could accurately predict subsequent decline to dementia. Logistic regression analyses were applied to (1) 213 nondemented elderly with a Global Deterioration Scale (GDS) score of 1, 2, or 3, of whom 74 (35%) subsequently declined to any diagnosis of dementia, and (2) a diagnostically more restricted subset of this sample (N = 179), of whom 56 (31%) declined to a diagnosis of probable Alzheimer's disease (AD). The mean follow-up intervals were 3.8 and 3.7 years, respectively. A small set of baseline neuropsychological measures (especially a Paragraph Delayed Recall Test) significantly differentiated decliners from nondecliners to dementia or AD, after accounting for the contribution of age, sex, education, follow-up interval, and the rating of global clinical status. When examined in combination with the other factors or alone, the cognitive tests produced reasonably high specificities (91%-97%) and sensitivities (73%-89%). Using the obtained regression model, a similar level of classification accuracy was replicated on an independent sample of 119 nondemented elderly. A subanalysis of the high-risk GDS 3 subgroup indicated that cut scores from the paragraph test distinguished nondecliners from decliners (overall accuracies 87%-91%), implying that this assessment may accurately predict future cognitive status in elderly with mild cognitive impairment.

The differential diagnosis of Alzheimer's disease. Cerebral atrophy versus normal pressure hydrocephalus.

This article summarizes the neuroradiology of Alzheimer's disease (AD) and details the radiologic features that permit the identification of patients with normal pressure hydrocephalus (NPH). Patients with presumed AD show a characteristic atrophy pattern with specific involvement of the temporal lobes and hippocampus. These findings have prognostic implications. Patients with NPH typically show severe motoric and gait deficits and initially mild cognitive impairment. Marked improvement is shown in select patients after ventricular shunting.