A. Charlanes

Adherence to Anticholinergic Therapy and Clean Intermittent Self-Catheterization in Patients With Multiple Sclerosis

Purpose To evaluate adherence to anticholinergic therapy (AT) and clean intermittent self-catheterization (CISC) in patients with multiple sclerosis (MS) and to identify factors associated with poor adherence. Methods This single-center study prospectively included 49 patients suffering from MS who had been prescribed AT and/or CISC. Adherence was evaluated using a self-report questionnaire. The Expanded Disability Status Scale (EDSS), Patient Global Impression of Improvement, Mini-Mental State Examination, Urinary Symptom Profile, and Hospital Anxiety and Depression (HAD) instruments were administered, and the number of daily anticholinergic pills and/or catheterizations was noted. Whether patients were receiving concomitant intradetrusor botulinum toxin injections was assessed, as were barriers to treatment, side effects, number of spontaneous micturitions, reasons for the prescription, satisfaction, and difficulties. Results Only 38% of patients were adherent to AT. Experiencing side effects was related to nonadherence (P=0.02). Only 29% of patients were adherent to CISC. More intense voiding dysfunction (P<0.001), a higher frequency of CISC (P=0.03), and a higher EDSS score (P=0.02) were associated with better adherence. Conversely, the HAD score (P<0.001), depression (P<0.001), the persistence of spontaneous micturition (P<0.001), a blocking sensation during catheterization (P=0.04), and the need to adapt one’s posture or gesture to perform catheterization (P=0.04) were associated with poorer adherence. Conclusions Adherence to AT and CISC was poor in patients with MS suffering from bladder dysfunction. Several factors related to nonadherence were identified in this study, and addressing these factors might help to improve treatment adherence.

Specificity of Lower Urinary Tract Symptoms in Neuromyelitis Optica in Comparison With Multiple Sclerosis Patients

Purpose The aim of this study was to describe lower urinary tract symptoms in neuromyelitis optica (NMO), and to compare these data with urinary disorders observed in multiple sclerosis (MS) patients. Methods Retrospective study of data collected from January 1997 to July 2017 using the database from a Neuro-Urology Department of a university hospital. NMO and MS patients were matched for sex, age, and Expanded Disability Status Scale (EDSS) Results Twenty-six patients with NMO were included and compared with 33 MS patients. Mean age was 41.6 years (standard deviation [SD], 14,8), mostly female patients (24 vs. 2 males). Mean EDSS was 4.6 (SD, 1.8) in the 2 groups. In NMO group, 57% of the patients (n=15) had overactive bladder with urgency and urge incontinence and 38.5% (n=10) of them had nocturia. Voiding symptoms was observed in 69.2% of the patients (n=18); 42.3% of NMO patients performed self-intermittent catheterization versus 12.1% in MS patients (P=0.012). Low bladder compliance and severe urinary tract infections (pyelonephritis) were more frequent in NMO than in MS patients (respectively 15% vs. 0%, P=0.016 and 42% vs. 12%, P=0.024). Conclusions Lower urinary tract symptoms, especially overactive bladder and urinary retention, are frequent in NMO. Low bladder compliance, serious urinary infections, and high prevalence of urinary retention requiring self-intermittent catheterization are the main symptoms significantly more frequent than in MS.

Emptying cystometry: A feasibility and validation pilot study on female patients

INTRODUCTIONnTo assess the feasibility and the accuracy of emptying cystometry in order to simplify the manometric follow-up of overactive detrusor in neurological patients under anticholinergic or botulinum toxin injections.nnnMATERIALnFemale patients with a stable detrusor underwent both a conventional cystometry and sequential measurements of bladder pressure during emptying (emptying cystometry). At the end of the standard cystometry, a CH12 urinary catheter was introduced in the bladder and was connected to a three-way stopcock. The second way of the stopcock permitted the emptying. The third way of the stopcock was connected to a vertical graduated tube to measure the bladder pressure each 50mL during the bladder emptying.nnnRESULTSnEleven female patients were included (mean age: 59.4years). Nine patients (82%) had neurogenic bladder. Mean cystometric capacity was 439mL (SD: 35mL). During the emptying cystometry, 8 to 10 measures were taken (mean: 9.4). The mean detrusor pressure was 1.7cmH2O (SD 2.1) for the filling cystometry and 2.3cmH2O (SD: 2.7) for the emptying cystometry. The agreement between the detrusor pressure between the two cystometries was good with intra-class correlation coefficient at 0.66 [0.48-0.77]xa0-xa0and the correlation was high (r=0.7; P<0.000001).nnnCONCLUSIONnIn a small, selected sample of patients, emptying cystometry provides similar results of detrusor pressure to filling cystometry. This technique could constitute a home monitoring of bladder pressures in a selected population of patients with intermittent catheterization in whom a manometric follow-up of detrusor overactivity is required.nnnLEVEL OF EVIDENCEn4.

Démonstration neurophysiologique d’un réflexe périnéo-vésico-sensitif inhibiteur

INTRODUCTIONnNeed to void level depends on two parameters, bladder volume and attentional process. If it is well known that the maximum voluntary contraction of the perineal muscles may transiently inhibit the micturition reflex itself, no work demonstrates the effect of this contraction on the intensity of the need itself.nnnMETHODSnAn experimental, prospective, open, monocentric study was conducted between March and April 2017. In total, 15 subjects with no neurological history or neuro-perineal disorders consulting for functional constipation were included. Need to void level was evaluated by means of an electronic urgentometer. A control contraction of the dominant hand muscles was compared to a voluntary contraction of the external anal sphincter during a strong desire to void (B3). These contractions were recorded by means of surface electromyography. The main evaluation criterion was the comparison between the difference in visual analogic scale of the desire to void before (VAS-base) and after control voluntary contraction (VAS-hand) versus the same index (BAS-base then VAS-anal) after contraction of the external anal sphincter during a new B3. The comparison of maximum bladder capacities (MBC) measured after each record was the secondary endpoint. Wilcoxon signed rank test was used for statistical analysis.nnnRESULTSnVoiding desire VAS decreased significantly (-13.14±12 vs -1.5±6; P=0.03) and MBC increased significantly (502.43±96.71mL vs 435.78±125.54mL; P=0.02) after anal compared to control contraction.nnnCONCLUSIONnThis study suggests the existence of sensitive pathways inhibition by perineal contraction through a sensitive perineo-vesical inhibitory reflex.nnnLEVEL OF EVIDENCEn3.

Reproductibilité du calendrier mictionnel chez les patients atteints de sclérose en plaques. Étude prospective monocentrique

INTRODUCTIONnMultiple sclerosis (MS) is a neurological condition characterized by variable levels of symptoms. This variability could also affect bladder dysfunction and impact on the reproducibility or stability of bladder diary (BD). The aim of the study is to investigate the reproducibility and reliability of BD in MS, and then determine its linked factors.nnnMETHODSnThe MS patient provided a 21xa0days BD and they documented the time of every void. The main criterion was assessed by voiding frequency, represented by the coefficient of variation (CV=average/standard deviation), expressed as a percentage. Two groups were described: stable BD group (CV≤15xa0%) and instable BD group (CV>15xa0%). Secondary criteria were completion of BD (complete or not) and the difference of voiding frequency variation between weekend and week.nnnRESULTSnThirty-one patients were included (mean age 51.06xa0years, SD 11.33) with 65xa0% of women. Mean CV is 23xa0% (SD 0.11). The mean completion of BD was 19.35xa0days (SD 3.99). 8xa0patients had a CV≤15xa0%. Stable group was older than instable group (P=0.03). There was no other difference between the 2xa0groups. There is a strong correlation between mean voiding frequency weekend and week (ρ=0.94, P<0.05). The longer duration of BD, the less reliability is notified.nnnCONCLUSIONnBD is not a stable reproducible in MS population. Both lack of compliance or variability of LUTS in MS may explain the unreliability of BD. However, BD utility should be discussed in this population.nnnLEVEL OF EVIDENCEn4.

Intermittent Catheterization Adherence Scale (ICAS): A new tool for the evaluation of patient adherence with clean intermittent self-catheterization

Patients who have successfully acquired the intermittent self‐catheterization (ISC) technique can be expected to use it on a long‐term basis. The aim of the present study is to present a validated evaluation scale, referred to as the ICAS (Intermittent Catheterization Adherence Scale), which can be used to assess long‐term patient adherence to prescribed ISC treatment.

Lower Urinary Tract Symptoms in Elderly Population With Multiple Sclerosis

Purpose The aim of this study is to compare the clinical and urodynamic characteristics of urinary disorders in multiple sclerosis (MS) patients in a geriatric population with a nongeriatric population. Methods This study was conducted retrospectively between 2010 and 2016. Each patient with MS aged 65 and older was matched with 2 patients with MS aged less than 65 in sex, form of MS, and Expended Disability Status Scale (EDSS). Demographic data, urinary symptoms, treatment, quality of life, repercussion of lower urinary tract symptoms on daily life activities and psychological state and urodynamic parameters were collected. Differences between the 2 populations were evaluated using Student test, chi-square, or Fischer tests. Results Twenty-four patients with MS aged 65 and older (mean age, 69.8 years) were matched with 48 patients aged less than 65 years (mean age, 49.4 years). Maximum urethral closure pressure was lower in the elderly population than in the nongeriatric population (mean±standard deviation [SD]: 35.6±18.5 cm H2O vs. 78.2±52.3 cm H2O, P<0.001). In the male population, there was no statistical difference in any other clinical or urodynamic endpoints. In the female population, voiding symptoms was more described in the nongeriatric population (Urinary Symptom Profile low stream: 3.4±3.5 vs. 1.7±2.4, P=0.04), geriatric population had less urinary treatment (P=0.05). LUTS had less impact on quality of life (Qualiveen: 1.4±1.0 vs. 2.1±0.9, P=0.02) on the geriatric population than in the nongeriatric of female MS patients. Conclusions Geriatric population of MS has few differences of urinary disorders compared to a nongeriatric population with EDSS, sex, and MS form equal. However, the psychological impact of these urinary disorders is less important in female geriatric population.

Use of a specific questionnaire and perineal electromyography to assess neuropathic pain after radical retropubic prostatectomy

Objective Prostate cancer is the most frequent cancer in men and radical retropubic prostatectomy (RRP) is one of the first-line treatment. However, RRP has some side effects and can lead to chronic perineal pain. The objective of the study was to determine in patients suffering from perineal pain after RRP the possibility of a neurogenic damage by means of a specific questionnaire dedicated to track down neuropathic pain. Methods Forty patients were explored by a specific and validated questionnaire, the Neuropathic Pain Symptom Inventory (NPSI). Patients were divided into two groups: Group A with an NSPI score ≥4 was considered as suffering from neuropathic pain, and Group B was considered as a control group without neuropathic pain (NSPI score <4). All patients had a perineal electrophysiological testing to confirm the possibility of a neurogenic damage. Results Group A was composed by 13 men and Group B by 27 men, with mean age 72.45 years and mean duration of pain 2.7 years. In Group A, the most frequent symptoms were burning sensation, electrical shock and numbness. Location of the pain was global perineal area (8/13), anus (10/13), penis (5/13) and glans penis (2/13). Electromyography (EMG) findings confirmed the presence of denervation and neurogenic damages compared with controls (p < 0.001). Conclusion One third of the patients consulting for chronic pain following RRP had probably a neuropathic lesion leading to a chronic perineal pain as suggested by an NSPI score ≥ 4 and EMG alterations.

Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies

BACKGROUNDnPelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject.nnnOBJECTIVEnThis article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed.nnnMETHODSnWe performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date.nnnRESULTSnWe selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it.nnnCONCLUSIONnPelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.