Raoul Vereecken

Hemospermia Owing to Utricular Cyst: Embryological Summary and Surgical Review

We report the first case of hemospermia owing to a utricular cyst. The embryologic distinction between utricular cysts, which are of endodermal origin, and müllerian duct cysts, which are of mesodermal origin, is described. The surgical management of utricular and müllerian duct cysts is reviewed, stressing the difficulty and hazards of attempts at complete excision and the efficacy of less heroic surgical procedures.

Tethered cord syndrome in occult spinal dysraphism Timing and outcome of surgical release

Objective To investigate the influence of neurosurgical intervention on the appearance of upper motor neuron (UMN) signs in newborns diagnosed with occult spinal dysraphism and tethered cord (TC) during the first month of life. Methods A prospective study (1990 to 1996) of 22 consecutive newborns with occult spinal dysraphism monitored for the appearance of UMN signs. Untethering was performed when neurologic or urodynamic investigation indicated the presence of UMN dysfunction. Results Of 22 patients, 10 remained free of UMN symptoms during follow-up (mean, 67 ± 22 months). Untethering was performed in 12 of 22 patients because of the presence of UMN symptoms. In 7 of these 12 patients, there was a documented asymptomatic period of 13 ± 11 months before the onset of UMN symptoms. Untethering at a mean age of 18 ± 17 months restored normal neurologic and urinary function in all patients (mean postoperative follow-up, 25 ± 16 months). Of the 12 children, 5 presented with UMN signs at birth. In these children, untethering was performed at a mean age of 9 ± 5 months. In two of these five patients, UMN symptoms did not resolve after surgery, and ongoing conservative bladder treatment was required (mean follow-up, 37 ± 14 months). In none of the 12 operated children did signs of retethering occur. Conclusions A significant number (10/22) of children born with occult spinal dysraphism and TC did not develop UMN symptoms during follow-up; neurosurgical correction after the appearance of an UMN sign restored normal neurologic and urinary function in all children; and untethering in children presenting at birth with UMN symptoms resulted in poorer outcome.

Urethral Instability: Related to Stress and/or Urge Incontinence?

Urethral instability (pressure variations of more than 15 cm. water during bladder filling) was noted in 12 of 34 women with bladder instability and 13 of 139 with a stable bladder. Of the patients 10 had urge, 5 mixed and 8 genuine stress incontinence, while 1 had enuresis and 1 had recurrent cystitis. A clear correlation between urethral pressure variations and electromyographic fluctuations in the anal and/or urethral sphincter was found in 14 of 17 patients. Only urethral pressure variations of more than 35 cm. water are reported as provoking urgency. Different types of pressure fluctuations are described but no fundamental differences or causative factors were found. A nervous rather than a vascular factor is designated as the main cause for urethral instability.

Do posture and straining influence urinary-flow parameters in normal women?

The influence of posture of the pelvis and straining on urinary flow was investigated in 21 normal women, mainly physiotherapists, who were asked to urinate on an uro‐flow chair at their usual time and frequency. Subjects were at random instructed to urinate in five different test situations: anteversion, anteversion with straining, retroversion, retroversion with straining, and forward bending without straining. The urinary‐flow parameters investigated were volume, peak flow, time to peak, peak‐to‐end time, total time, and mean flow. The analysis was done by means of analysis of variance but only for micturition volumes >150 mL. The morphology of the urinary‐flow curves was examined for the presence of irregularities and increasing (after top) or decreasing (for top) curve tops and after‐dribbling. Results demonstrated no significant differences for peak flow, total time, and mean flow in the anteversion, retroversion, and the forward‐bending position. This holds for test situations and re‐test controls. However, straining increased the peak flow and mean flow rates in all positions and in all women, whereas it reduced the total voiding time. The voided volumes were lowest in anteversion. Irregularities were less frequent in the forward‐bending position. It can be concluded that the forward‐bending position is the most preferable urinating position to relax the pelvic floor muscles. Neurourol. Urodynam. 19:3–8, 2000.

INTRAVESICAL APPLICATION OF A STABLE OXYBUTYNIN SOLUTION IMPROVES THERAPEUTIC COMPLIANCE AND ACCEPTANCE IN CHILDREN WITH NEUROGENIC BLADDER DYSFUNCTION

PURPOSE To improve patient compliance with and acceptance of intravesical oxybutynin therapy for neurogenic bladder dysfunction we developed a stable oxybutynin solution that eliminates the complicated crushing procedure. MATERIALS AND METHODS From January 1995 to January 1997 we prospectively evaluated 15 children with a mean age of 6.1 years with persistent detrusor hyperactivity or significant side effects on oral oxybutynin therapy who received intravesically 0.2 mg./kg. (maximum 5 mg.) of a stable oxybutynin solution (5 mg./5 ml., pH 5.85) twice daily. RESULTS The oxybutynin solution remained stable up to 24 months. In 13 of the 15 children therapeutic compliance was excellent. Detrusor hyperactivity decreased and systemic side effects were absent or minimal. After 4 and 24 months mean cystometric bladder capacity plus or minus standard error of mean increased from 114+/-15.2 to 161+/-26.6 and 214+/-21.7 ml. (p <0.01), mean ratio of cystometric-to-expected bladder capacity increased from 0.88+/-0.12 to 1.18+/-0.14 and 1.24+/-0.16 (p <0.01), and end filling bladder pressure decreased from 57.0+/-7.1 to 25.6+/-4.4 and 30.8+/-4.4 cm. water (p <0.01), respectively. CONCLUSIONS Intravesical instillation of a specially prepared oxybutynin solution is safe and reliable in children with persistent detrusor hyperactivity or side effects on oral oxybutynin therapy. Eliminating the complex crushing preparation of the solution by the child or parent has made this therapy easy to use and acceptable in the long term.

URETHRAL INSTABILITY AS AN IMPORTANT ELEMENT OF DYSFUNCTIONAL VOIDING

PURPOSE We monitored detrusor and urethral behavior during bladder filling in girls with dysfunctional voiding (incomplete perineal relaxation) to determine the causes of this pathological condition. MATERIALS AND METHODS In 15 girls without neuropathy but with a staccato voiding pattern in whom symptoms of urinary tract infection and urge incontinence were refractory to treatment we recorded urethral and bladder pressure, and anal sphincter needle electromyography throughout slow bladder filling. RESULTS Urethral instability was observed in 8 of the 15 girls as urethral pressure decreases with short periods of electromyography silence (6) or as intermittent urethral pressure increases with short perineal spasms (2). Detrusor instability was noted in 12 girls, while bladder pressure was normal in 1 and hypoactive in 2. In 6 cases of an unstable bladder urethral pressure decreases with silent electromyography periods were also noted. In 1 case low basic urethral pressure had short periods of increased pressure with electromyography bursts. In another case high compliance bladder uninhibited sphincter contractions were noted throughout filling. CONCLUSIONS Dysfunctional voiding is a misleading term since a pathological condition is also present during the bladder filling phase. Frequently observed detrusor and urethral instability may explain the urge sensation during filling and the staccato voiding phase.

Neuro-muscular dysfunction of the lower urinary tract in multiple sclerosis.

Urological problems in M. S. patients are very frequent and are usually very disabilitating. Complaints will often be misleading. Urodynamic investigations play a most important part in the diagnosis but are carried out with more difficulty than in other patients. The lower urinary tract dysfunction is classified as advised by the I.C.S. Committee. Detailed figures are given in the text.Evolution of urological disorders in M.S. is unpredictable. Treatment has to be conservative, flexible and reversible if possible. The goal of the treatment is to get a balanced bladder and complications due to urological manipulations must be avoided.

A Critical View on the Value of Urodynamics in Non-Neurogenic Incontinence in Women

Abstract: The requirements for reliable urodynamics are standardized techniques, including uniform pressure sensors, filling rates, position and posture during the investigation, and uniform diuresis. Physiological variations in flow and urethral pressure profile (UPP) (menstrual cycle, intensity of coughing, circadian variations) must be considered. Parameters of the UPP (maximum (closure) urethral pressure, pressure–transmission ratio and leak-point pressure) are useful if interpreted with caution. Uninhibited detrusor contractions are more frequently recorded in ambulatory urodynamics, and range from ‘subthreshold’ to very strong. No quantification formulae correlate with subjective symptoms or degree of urge (incontinence). Mixed incontinence can make the results of surgery worse, but do not so necessarily. Postoperative dysuria cannot be predicted from urodynamics, as surgical factors are more important. Electromyography is not useful in non-neurogenic female incontinence. For routine non-neurogenic incontinence extensive urodynamic testing can be reduced to one pressure measurement; more complicated cases must be tested by a physician with large practical experience and a theoretical background.

Detrusor pressure in ambulatory versus standard urodynamics.

An ambulatory urodynamic examination was performed on 28 non‐neurogenic incontinent patients in whom classical cystometry could not confirm objectively the history and clinical diagnosis of urinary incontinence. In 12 of 13 stress‐incontinent patients, real leakage could be demonstrated. Of 15 patients with mixed incontinence, bladder instability was found in 8 and urethral instability in 2. Voiding detrusor pressures in ambulatory measurements were ∼10 cm H2O higher than in classical cystometry, although the voided volumes were lower. Advantages and pitfalls of ambulatory detrusor pressure monitoring are discussed. Neurourol. Urodynam. 17:129–133, 1998.

Solitary benign schwannoma in the psoas muscle

Schwannomas, which also are referred to as neurinoma or neurilemmoma, are rare. We report a case of a solitary benign schwannoma in the psoas muscle, which was not associated with von Recklinghausens disease. The tumor was excised successfully. Its appearance on clinical examination is described, the preoperative investigations and operative findings are presented, and the literature is reviewed.