Brigitte Schurch

Supraspinal Control of Urine Storage and Micturition in Men—An fMRI Study

Despite the crucial role of the brain in the control of the human lower urinary tract, little is known about the supraspinal mechanisms regulating micturition. To investigate the central regulatory mechanisms activated during micturition initiation and actual micturition, we used an alternating sequence of micturition imitation/imagination, micturition initiation, and actual micturition in 22 healthy males undergoing functional magnetic resonance imaging. Subjects able to micturate (voiders) showed the most prominent supraspinal activity during the final phase of micturition initiation whereas actual micturition was associated with significantly less such activity. Initiation of micturition in voiders induced significant activity in the brainstem (periaqueductal gray, pons), insula, thalamus, prefrontal cortex, parietal operculum and cingulate cortex with significant functional connectivity between the forebrain and parietal operculum. Subjects unable to micturate (nonvoiders) showed less robust activation during initiation of micturition, with activity in the forebrain and brainstem particularly lacking. Our findings suggest that micturition is controlled by a specific supraspinal network which is essential for the voluntary initiation of micturition. Once this network triggers the bulbospinal micturition reflex via brainstem centers, micturition continues automatically without further supraspinal input. Unsuccessful micturition is characterized by a failure to activate the periaqueductal gray and pons during initiation.

Dysfunction of lower urinary tract in patients with spinal cord injury

Over the past 50 years, the mortality for urorenal cause in patients with spinal cord injuries (SCI) has decreased from over 75% to 2.3%, as a result of dramatic improvements in the diagnosis and management of lower urinary tract dysfunction (LUTD). The aims of this chapter are to assess the physiopathology of upper and lower motor neuron lesion on bladder and sphincter function after SCI, to give an overview of required clinical and instrumental examination and to discuss treatment modalities. Videourodynamic examination plays a key role in the assessment and follow-up of LUTD in SCI patients, in conjunction with neurophysiological and radiological examinations. The cornerstone of bladder management in SCI is clean intermittent self-catheterization, but often other treatments are needed to achieve full continence, to reduce infections and stone formation, to protect the upper urinary tract from excessive bladder pressure, and to prevent chronic renal failure. Treatments may be pharmacologic (i.e., anticholinergic drugs and botulinum toxin) or surgical (by enterocystoplasty or urinary diversion). In selected cases, neuromodulation and sacral root stimulation can be used to reduce detrusor overactivity and empty the bladder. Management of LUTD in SCI patients requires a deep knowledge of spinal cord medicine and functioning of patients with neurologic disability.

Long‐term outcomes and risks factors for failure of intradetrusor onabotulinumtoxin A injections for the treatment of refractory neurogenic detrusor overactivity

Aims of this study were to assess the long‐term outcomes of Intradetrusor injection of OnabotulinumtoxinA (Botox® injection) associated with clean intermittent‐catheterization (CIC) for the treatment of neurogenic detrusor overactivity (NDO) and to identify risk factors for failure.

Intradetrusor Injections of Botulinum Toxin A in Adults with Spinal Dysraphism

Purpose: The aim of the current study was to determine the outcomes of botulinum toxin A intradetrusor injections in adult patients with spina bifida. Materials and methods: All patients with spinal dysraphism who underwent intradetrusor injections of botulinum toxin A from 2002 to 2016 at a total of 14 centers were retrospectively included in analysis. The primary end point was the global success of injections, defined subjectively as the combination of urgency, urinary incontinence and detrusor overactivity/low bladder compliance resolution. Univariate and multivariate analysis was performed to seek predictors of global success. Results: A total of 125 patients were included in study. The global success rate of the first injection was 62.3% with resolution of urinary incontinence in 73.5% of patients. All urodynamic parameters had improved significantly by 6 to 8 weeks compared to baseline, including maximum detrusor pressure (–12 cm H2O, p <0.001), maximum cystometric capacity (86.6 ml, p <0.001) and compliance (8.9 ml/cm H2O, p = 0.002). A total of 20 complications (3.6%) were recorded for the 561 intradetrusor botulinum toxin A injections, including 3 muscular weakness complications. The global success rate of the first injection was significantly lower in patients with poor compliance (34.4% vs 86.9%, OR 0.08, p <0.001). On multivariate analysis poor compliance was associated with a lower global success rate (OR 0.13, p <0.001). Female gender (OR 3.53, p = 0.01) and patient age (OR 39.9, p <0.001) were predictors of global success. Conclusions: Intradetrusor botulinum toxin A injections were effective in adult patients with spina bifida who had detrusor overactivity. In contrast, effectiveness was much lower in adult patients with spina bifida who had poor bladder compliance. The other predictors of global success were female gender and older age.

The efficacy of botulinum toxin A and sacral neuromodulation in the management of interstitial cystitis (IC)/bladder pain syndrome (BPS), what do we know? ICI-RS 2017 think thank, Bristol

This manuscript aims to address the evidence availale in the literature on the efficacy of Botulinum Toxin A (BoNT‐A) and sacral neuromodulation (SNM) in patients suffering from Interstitial Cystitis (IC)/BPS and propose further research to identify mechanisms of action and establish the clinical efficacy of either therapy.