Ranan Dasgupta

Bladder, bowel and sexual dysfunction in multiple sclerosis: Management strategies

Although patients with multiple sclerosis (MS) are likely to have problems with bladder, bowel and sexual function, these problems have often been neglected in the past. Bladder dysfunction produces symptoms of urgency, frequency and urge incontinence (due to bladder overactivity and incomplete emptying), and is found in up to 75% of patients with MS. The mainstay of drug treatment for neurogenic bladder overactivity is anticholinergic medication, although intravesical treatments have also been proposed, such as the vanilloids and botulinum toxin, as well as sublingual cannibanoids. There has been much progress with pro-erectile agents in recent years, notably the use of sildenafil citrate, which has been shown to be particularly efficacious in these patients. Other agents include apomorphine hydrochloride and newer phosphodiesterase 5 inhibitors; however, the efficacy of these drugs in patients with MS remains to be proven. Research in female sexual dysfunction is also progressing, although this aspect of patient well being has only recently been addressed; the reported development of a classification system for the condition is likely to help categorise future treatments. Unlike bladder and sexual dysfunction, there have been rather limited advances in the treatment of faecal incontinence and constipation specifically for patients with MS, despite a prevalence of up to 50%. This review highlights the strategies for these types dysfunction commonly seen in patients with MS, with report of recent pharmacological developments.

Functional imaging and the central control of the bladder

The central control of the bladder is a complex, multilevel process. Recent advances in functional brain imaging have allowed research into this control in humans. This article reviews the functional imaging studies published to date and discusses the regions of the brain that have been implicated in the central control of continence. Brain regions that have been implicated include the pons (pontine micturition center, PMC), periaqueductal gray (PAG), thalamus, insula, anterior cingulate gyrus, and prefrontal cortices. The PMC and the PAG are thought to be key in the supraspinal control of continence and micturition. Higher centers such as the insula, anterior cingulate gyrus, and prefrontal regions are probably involved in the modulation of this control and cognition of bladder sensations, and in the case of the insula and anterior cingulate, modulation of autonomic function. Further work should aim to examine how the regions interact to achieve urinary continence. J. Comp. Neurol. 493:27–32, 2005.

Long-term results of sacral neuromodulation for women with urinary retention.

To review the long‐term results of sacral nerve stimulation in the treatment of women with Fowlers syndrome, over a 6‐year period at one tertiary referral centre.

Sexual and urological dysfunction in multiple sclerosis: better understanding and improved therapies

&NA; The fundamental strategy in treating multiple sclerosis patients with unstable bladders involves a combination of suppressing urgency and ensuring effective urinary drainage. Anticholinergics remain the first‐line treatment, but alternative therapies are undergoing clinical trials. With a range of new proerectile oral medications available, interest has grown in treatment of multiple sclerosis‐related erectile failure. Female sexual dysfunction is also now gaining some attention, with new classification criteria and methods for assessing and treating these patients.

Urinary retention in women: its causes and management.

Urinary retention in women is a diagnostic and therapeutic challenge to urologists and to all involved in the treatment of the condition. The patients referred to a single institution with this condition over a 4‐year period were audited and the data are presented. The importance of Fowlers syndrome is described, as is the value of sacral nerve stimulation in this condition. In another paper, authors from France present evidence of occult dysautonomia in Fowlers syndrome.

Cerebral mechanisms and voiding function

Some of the most recent work investigating the cerebral mechanisms involved in bladder control has been very helpful in adding to our understanding of bladder dysfunction. The group behind this work, from London, presents a mini‐review which will help to update our knowledge in this area.

Percutaneous nephrolithotomy: does position matter? - prone, supine and variations.

Purpose of review The evolution of percutaneous renal stone surgery has recently seen an increasing number undergoing surgery in the supine position rather than just the classical prone technique. Several advantages have been proposed with the supine approach, including benefits for anaesthesia (cardiovascular and airway), the patient (reduced transfer-related injuries), and surgeon (combined retrograde and antegrade surgery, and ergonomics). As the supine technique and variations have now been practised for several years, it is timely to review whether it has been adopted universally and what factors may lead to preference for one approach over another. Recent findings There have been several retrospective reports, but only two prospective randomized trials published in the literature, comparing the techniques. There have also been recent attempts at establishing national and international databases for percutaneous nephrolithotomy (PCNL) surgery to try and describe the practice patterns for this surgery, and also the factors that influence the decision to adopt a particular position. Although there appear to be no clear overall benefits for one position over another, and practice is likely to remain fairly surgeon-specific, there are some cases in which the supine PCNL may be preferable (e.g. in obese patients). Summary Along with the development of centres offering this surgical technical variation, endourology training programmes will increasingly offer exposure to supine PCNL, which may then affect the global practice patterns.

Urinary tract infection

Infected urine B L A D D E R C R O S S S E C T I O N The urinary tract is made up of the bladder, the urethra, the ureters, and the kidney. Urine is made by the kidneys. It then flows down the ureters to the bladder where it is stored before being passed out of the body through the urethra. Urine is usually a sterile fluid, but when it is infected, it contains bacteria. Urinary tract infections (UTIs) are very common, especially in women. When they happen over and over, this is called recurrent UTI. If your primary care doctor diagnoses recurrent UTI, you may be referred to a urologist, a doctor with specialized education in the diagnosis and treatment of conditions in the urinary tract.

Lasers and Urinary Calculi

The application of novel technology and innovative surgical techniques has contributed greatly to the advance of endourology over the past two decades. Key developments include endoscopic access to the urinary tract and advances in intraand extra-corporeal stone fragmentation techniques. Of these techniques, laser technology has also been applied to other branches of urology including prostate surgery, ablation of urothelial tumors, and treating urinary strictures. The safe introduction of this potentially hazardous technology has required defining stringent safety guidelines, which encompass protection of both the patient and the user. In this chapter, physics of laser is discussed, along with the review of its application in treating stones.