John B. Nanninga

Effect of Intrathecal Baclofen on Bladder and Sphincter Function

A programmable baclofen pump was implanted in 7 patients for relief of severe spasticity. The patients experienced improvement in bladder and sphincter function. This system would seem to be of value in improving lower urinary tract function in patients with diseases that produce marked spasticity.

Use of Electrocoagulation in the Treatment of Vesicovaginal Fistulas

The role of electrocoagulation for the treatment of vesicovaginal fistulas has not been clearly defined. To determine the use of this therapeutic modality, 15 cases of fistulas treated with electrocoagulation were retrospectively reviewed. Fulguration represented the primary treatment in 12 patients and the secondary treatment in 3 after an initial attempt at open surgical closure failed. In all instances fistula size was estimated to be 3.5 mm. or less. A Bugbee electrode, which was inserted into the fistula either cystoscopically or vaginally, was used to destroy the epithelial lining of the fistula tract. Following the procedure the bladder was decompressed with a large indwelling Foley catheter for at least 2 weeks. Fulguration was successful as the sole treatment modality in 9 of 12 patients (75%) and as an alternative intervention after failure of an open surgical repair in 2 of 3 (66%). Therefore, 11 of the 15 women (73%) had complete resolution of the fistulas with this technique. We conclude that fulguration is usually effective in managing patients with vesicovaginal fistulas a few millimeters in size or less. This technique should be used as an initial treatment for appropriately selected patients and in women with small residual fistulas after open surgical failure.

Pathophysiology and Treatment of Enuresis in adults

Monosymptomatic nocturnal enuresis (MNE) in children is partly the result of inadequate reduction in the rate of urine output at night. This nocturnal polyuria is due to the lack of a rise in the anti-diuretic hormone, arginine vasopressin (AVP), and can be reduced or eliminated by treatment with desmopressin at bedtime. Since there is a 1% incidence of MNE among adults, this study investigated the circadian pattern of solute and water balance in nine young adult enuretics before and during desmopressin therapy and compared the results with nine-age- and sex-matched, healthy controls. Before treatment, enuretics and controls had similar total fluid intake, urine output, urine osmolality, plasma osmolality, plasma total protein, mean arterial pressure and plasma AVP. The circadian pattern of fluid intake was also normal in enuretics. This abnormality could not be attributed to a deficiency of plasma AVP or an increase in solute excretion, since both variables were similar to controls. Rather, their nocturnal polyuria appeared to be due to a marked nocturnal reduction in renal sensitivity to the antidiuretic effect of vasopressin. In seven enuretics, restudied during treatment with desmopressin (10-30 micrograms o.d.), circadian urine output was normal and enuresis was absent. These results indicate that: (i) The circadian pattern of urine output in healthy adults is largely due to a nocturnal decrease in solute excretion rather than a rise in plasma AVP; (ii) The subset of adults with persistent MNE also have nocturnal polyuria as a result of insensitivity to the antidiuretic action of AVP; (iii) These defects can be corrected by treatment with desmopressin.

Upper urinary tract abnormalities in multiple sclerosis patients with urinary symptoms.

OBJECTIVE To determine the prevalence of upper urinary tract complications in multiple sclerosis (MS) patients with urinary symptoms, and to determine if an association exists between degree of physical impairment and upper urinary tract complications. DESIGN AND SETTING A cohort study of MS patients seeking treatment at a freestanding, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 48 patients with MS, exacerbation-free for 6 months with symptoms of neurogenic bladder dysfunction. For each patient, demographic data, disease characteristics, and urologic history was obtained. Using the Kurtzke Expanded Disability Status Scale (EDSS), participants were divided into a control (EDSS < 7) and study (EDSS >/= 7) group. INTERVENTION Ultrasound examination of the upper urinary tract. MAIN OUTCOME MEASURE Significant MS-related abnormalities of the upper respiratory tract. RESULTS Ten of 48 patients (21%) had significant MS-related upper urinary tract abnormalities, which were evenly distributed between control and study groups. In the more disabled study group, abnormalities were associated with the symptom of urinary hesitancy (p < .05) and form of bladder management (p < .05). CONCLUSIONS Routine screening for upper urinary tract complications appears indicated in a select group of MS patients with urinary symptoms.

Long-Term Intermittent Catheterization in the Spinal Cord Injury Patient

Intermittent catheterization was used as a means of long-term bladder management in 85 patients with spinal cord injury. Of these patients followup data revealed that 28 (33 per cent) had reflux and/or hydronephrosis. Treatment in 15 patients consisted of increasing the frequency of catheterization to every 4 hours and avoiding high fluid intake during a relative short interval. Sphincterotomy was done in 3 patients, while 10 were placed on an indwelling catheter because of an inability to adapt to or refusal of other forms of treatment. The upper urinary tract changes noted seemed to be related to increased intravesical pressure, either from too long an interval between catheterizations or from marked detrusor hyperreflexia with sphincter obstruction. Close followup seems necessary in these patients.

Silent hydronephrosis, a hazard revisited

Six patients with neurogenic bladder secondary to spinal cord injury were seen in our Centre for routine follow-up. All of these individuals had attained the catheter-free state by various means and were, by their standards, functioning very well. They had gone from 6 months to 2½ years without genito-urinary re-evaluations. One individual had a normal urogram i year after catheter removal and then 2 years later was noted to have bilateral hydronephrosis. Development of silent hydronephrosis in the catheter-free state, its treatment, and a regimen for following patients are discussed.

The effect of sacral nerve stimulation for bladder control during pregnancy: a case report.

Neural stimulation was used to reduce bladder hyperreflexia and incontinence in a woman with myelodysplasia. The stimulation was delivered via an electrode placed in a sacral foramen and attached to a stimulator placed subcutaneously. The patient activated the device to inhibit the bladder and deactivated it to allow voiding. The device proved to be helpful in reducing bladder hyperreflexia and its use during pregnancy did not seem to have any adverse effect.

Urosonography in Spinal Cord Injury Patients

Urosonography, ultrasound of the urinary tract, is a noninvasive imaging method used to evaluate renal masses, renal parenchymal disease, hydronephrosis, bladder volume and calculi. The applicability of ultrasound was studied in 54 spinal cord injury patients by correlating uroradiological examinations with ultrasound. Emphasis was placed on ultrasonic imaging of ureterectasis and vesicoureteral reflux. Ultrasound confirmed all positive radiographic findings of renal and bladder abnormalities (renal calculi, chronic pyelonephritis, trabeculated bladder and bladder calculi), and yielded additional information in 27 per cent of the kidney and 13 per cent of the bladder studies. Ultrasound was used to confirm vesicoureteral reflux in 56 per cent of the patients and ureterectasis in 33 per cent. It is recommended that spinal cord injury patients undergo a baseline excretory urogram followed by periodical ultrasound examinations to detect hydronephrosis, renal parenchymal disease, and renal and bladder calculi, and to measure bladder volume and residual urine. Whenever real-time equipment and experienced ultrasonologists are available ultrasound can be used as an alternate to voiding cystourethrography to detect vesicoureteral reflux.

Improved results in vasovasostomies using internal plain catgut stents

Abstract Internal stents of 3-0 plain catgut gave an 86 per cent patency rate after vasovasostomy in 14 patients while externalized silkworm gut stents gave a 67 per cent patency rate in 21 patients. The internal stent technique does not require microsurgical instruments or specialized sutures. The use of the internal stent avoids having both a portal of entry for infection and an additional site for leakage of sperm with possible subsequent granuloma formation. The patency rates using internal stents compare favorably with those of any other technique now in use.

Reduction of bladder contractility after alpha-adrenergic blockade and after ganglionic blockade.

Seven spinal cord injured patients were evaluated with cystometry bladder, electromyography, and pressure profiles of the external urethral sphincter before and after phenoxybenzamine administration. Seven more patients were evaluated before and after mecamylamine administration. Both drugs reduced the contractility of the bladder. The reduction of bladder contractility may reflect decreased sympathetic stimulation to the bladder. Bladder electric potentials reflect the intrinsic tone of the detrusor muscle.