J. Kerdraon

Diagnosis and management of adult female stress urinary incontinence: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

Urinary incontinence is a frequent affliction in women and may be disabling and costly {LE1}. When consulting for urinary incontinence, it is recommended that circumstances, frequency and severity of leaks be specified {Grade B}. The cough test is recommended prior to surgery {Grade C}. Urodynamic investigations are not needed before lower urinary tract rehabilitation {Grade B}. A complete urodynamic investigation is recommended prior to surgery for urinary incontinence {Grade C}. In cases of pure stress urinary incontinence, urodynamic investigations are not essential prior to surgery provided the clinical assessment is fully comprehensive (standardised questionnaire, cough test, bladder diary, post-void residual volume) with concordant results {PC}. It is recommended to start treatment for stress incontinence with pelvic floor muscle training {Grade C}. Bladder training is recommended at first intention in cases with overactive bladder syndrome {Grade C}. For overweight patients, loss of weight improves stress incontinence {LE1}. For surgery, sub-urethral tape (retropubic or transobturator route) is the first-line recommended technique {Grade B}. Sub-urethral tape surgery involves intraoperative risks, postoperative risks and a risk of failure which must be the subject of prior information {Grade A}. Elective caesarean section and systematic episiotomy are not recommended methods of prevention for urinary incontinence {Grade B}. Pelvic floor muscle training is the treatment of first intention for pre- and postnatal urinary incontinence {Grade A}. Prior to any treatment for an elderly woman, it is recommended to screen for urinary infection using a test strip, ask for a bladder diary and measure post-void residual volume {Grade C}. It is recommended to carry out a cough test and look for occult incontinence prior to surgery for pelvic organ prolapse {Grade C}. It is recommended to carry out urodynamic investigations prior to pelvic organ prolapse surgery when there are urinary symptoms or occult urinary incontinence {Grade C}.

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. RESULTS A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events. CONCLUSIONS Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

Electrophysiological analysis of pudendal neuropathy following traction

Pudendal neuropathy is an unusual but important complication of orthopedic surgical procedures involving traction on the fracture table. We describe the clinical and electrophysiological features in six patients presenting with perineal sensory disorders and sexual dysfunction following surgical repair of femoral fracture, hip dislocation, or intra‐articular foreign body, in which the traction table was used. All underwent electrophysiological recordings: bulbocavernosus muscle electromyography (EMG), measurements of the bulbocavernosus reflex latencies (BCRLs), somatosensory evoked potentials of the pudendal nerve (SEPPNs), sensory conduction velocity of the dorsal nerve of the penis (SCVDNP), and pudendal nerve terminal motor latencies (PNTMLs). Signs of denervation localized to the territory of the pudendal nerve were found in 3 patients, normal BCRL in 6, abnormal SEPPNs in 4, and abnormal SCVDNPs and PNTMLs in all cases. The outcome at 2‐year follow‐up was good, except in one patient with initially unrecordable PNTML. Perineal electrophysiological examination can thus confirm the pudendal neuropathy and give prognostic information.

Clinical value of ipsi- and contralateral sacral reflex latency measurement: A normative data study in man

The latency of the bulbocavernosus reflex (BCR) evoked by electrical stimulation of the penis provides a measure of the conduction velocity over the sacral reflex arc at the S2–4 level but does not allow evaluation of the side affected since it results from the simultaneous excitation of both dorsal nerves of the penis (DNP) at the penile root. To evaluate the reliability of the side‐to‐side BCR latency measurement, this study compared the reflex characteristics of the response elicited by both DNP stimulation and unilateral DNP block. After a unilateral selective DNP anesthesic block, we found that the early response of the contralateral BCR is strictly ipsilateral with no differences in terms of latency, morphology, and reflex threshold from controls. This result may indicate that the side‐to‐side BCR latency measurement allows a comparative study of the respective right and left sacral reflex arcs in men. We found a mean inter‐latency difference of 1.8 ± 0.4 millisecond of the early BCR response after simultaneous recording of the right and left sides in 10 normal men. We established that an inter‐latency difference >3 milliseconds may be indicative of a significant alteration in the conduction over the sacral reflex arc. Neurourol. Urodynam. 19:565–576, 2000.

PUDENDAL NERVE TERMINAL SENSITIVE LATENCY: TECHNIQUE AND NORMAL VALUES

PURPOSE We evaluated a new technique to study the terminal sensory branches of the pudendal nerve in 30 normal men. MATERIALS AND METHODS To elicit response endorectal stimulation of the pudendal nerve was delivered just to the left then right of the ischiatic spine using an electrode. The sensory potential was recorded in the balanopreputial zone with ring contact electrodes wrapped around the shaft of the penis. From 5 to 40 responses were averaged to obtain the sensory potential. RESULTS The pudendal nerve terminal sensory response was obtained for each normal subject. Mean latency value plus or minus standard deviation was 5.35+/-0.97 milliseconds for the left side with a mean amplitude of 4.24 microV. and 5.33-/+0.77 milliseconds for the right side with a mean amplitude of 3.77 microV. CONCLUSIONS This method allows comparative study of the right and left terminal sensory branches of the pudendal nerve, and may be helpful in the diagnosis of different perineal disorders, such as sexual dysfunction, perineal pain and fecal incontinence, but further experience is necessary.

Cranberry versus placebo in the prevention of urinary infections in multiple sclerosis: a multicenter, randomized, placebo-controlled, double-blind trial

Objective: Our aim was to assess the usefulness of cranberry extract in multiple sclerosis (MS) patients suffering from urinary disorders. Methods: In total, 171 adult MS outpatients with urinary disorders presenting at eight centers were randomized (stratification according to center and use of clean intermittent self-catheterization) to cranberry versus placebo in a 1-year, prospective, double-blind study that was analyzed using a sequential method on an intent-to-treat basis. An independent monitoring board analyzed the results of the analyses each time 40 patients were assessed on the main endpoint. Cranberry extract (36 mg proanthocyanidins per day) or a matching placebo was taken by participants twice daily for 1 year. The primary endpoint was the time to first symptomatic urinary tract infection (UTI), subject to validation by a validation committee. Results: The second sequential analyses allowed us to accept the null hypothesis (no difference between cranberry and placebo). There was no difference in time to first symptomatic UTI distribution across 1 year, with an estimated hazard ratio of 0.99, 95% CI [0.61, 1.60] (p = 0.97). Secondary endpoints and tolerance did not differ between groups. Conclusion: Taking cranberry extract versus placebo twice a day did not prevent UTI occurrence in MS patients with urinary disorders. Trial Registration NCT00280592.

Suivi des patients après injection de toxine botulique intradétrusorienne: Recommandations de bonne pratique clinique chez le patient neurologique

Injections of botulinum toxin into the detrusor is a major evolution for treatment of neurogenic bladder. They are now considered as a treatment of choice, safe and efficient, in refractory neurogenic overactivity in catheterized patient. To date, there are no consensual practical guidelines for the follow-up of patients having been treated by intradetrusor botulinum toxin, whatever the indication of the treatment, functional, that is, for improving continence and overactive bladder syndrome or organic, that is, for treatment of high-detrusor pressure and their deleterious impact of urinary tract. This lack of guidelines leads to heterogeneity of treatment management and limit the definition of optimal modalities of intradetrusor botulinum toxin treatment in neurogenic patients. The aim of your work, prepared jointly with the International Francophone Neuro-Urological expert study group (GENULF), aimed at putting forward well-informed specific recommendations for the follow-up of patients having been treated by intradetrusor botulinum toxin for functional or organic indication of neurogenic detrusor overactivity.

Outcomes of intra-detrusor injections of botulinum toxin in patients with spina bifida: A systematic review

Bladder management in spina bifida patients relies on clean intermittent catheterization and oral antimuscarinics with a significant failure rate. The efficacy of intradetrusor injections of botulinum toxin has been confirmed in patients with spinal cord injury or multiple sclerosis but not in patients with myelomeningocele.

Place des explorations électrophysiologiques dans la prise en charge des prolapsus urogénitaux

Isolated pelvic organ prolapse or together with urinary or fecal incontinence are frequently associated with peripheral neuropathy. This peripheral neuropathy could be seen as the cause or sometimes the consequence of the prolapse itself. Most of the studies have looked at the relationships between neuropathy and fecal incontinence. However, concerning urogenital prolapses, it seems that any peripheral denervation would lead to an exacerbation of the prolapse due to the weakness of the pelvic floor. Electromyography and electrophysiological tests are the only options to demonstrate objectively the peripheral neuropathy associated with pelvic organ prolapse. Those tests should not be performed systematically but only if there is any clinical suspicion of an underlying neuropathy.

Switch to Abobotulinum toxin A may be useful in the treatment of neurogenic detrusor overactivity when intradetrusor injections of Onabotulinum toxin A failed

To assess the outcomes of switching to a different brand of botulinum toxin A (BTA, from Botox® to Dysport®) in case of failure of intradetrusor injections (IDI) of Botox® in the treatment of neurogenic detrusor overactivity (NDO).