Todd A. Linsenmeyer

Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study.

Abstract Objective: To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTis) in persans with spinal cord injury (SCI). Design: A prospective, double–blinded, placebo–controlled, crossover study. Participants: 21 individuals with neuragenie bladders secondary to SCI. Main Outcome Measures: Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts. Methods: lndividuals with neuragenie bladders due to SCI were recruited and randomly assigned to standardized 400–mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1–week “washout period,” participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count 2: 1 0 perhigh power field) in centrifuged urine. Participa nts with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7–day washaut period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead’s random effect approach. Results: There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups. Conclusion: Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTis in individuals with neuragenie bladders. Further Long–term studies evaluating specific types of bladder management and UTis will help to determine whether there is any role for the use of cranberries in individuals with neuragenie bladders.

LONG-TERM FOLLOWUP OF THE NORTH AMERICAN MULTICENTER UROLUME* TRIAL FOR THE TREATMENT OF EXTERNAL DETRUSOR-SPHINCTER DYSSYNERGIA

PURPOSE We determine the long-term efficacy and safety of the UroLume stent as minimally invasive treatment for external detrusor-sphincter dyssynergia in spinal cord injured men. MATERIALS AND METHODS A total of 160 spinal cord injured men with a mean age plus or minus standard deviation of 36.3 +/- 12.1 years (range 16 to 74) were prospectively treated with an endoprosthesis at 15 centers as part of the North American UroLume trial for external detrusor-sphincter dyssynergia. Urodynamic parameters, including voiding pressure, residual urine volume and bladder capacity, were compared before treatment and at 1, 2, 3, 4 and 5 years after treatment. RESULTS Mean voiding pressure was 75.1 +/- 28.2 cm. water before treatment in the 160 patients, and 37.4 +/- 23.9 at year 1 in 97, 39.5 +/- 22.2 at year 2 in 84, 42.6 +/- 27.3 at year 3 in 61, 46.3 +/- 33.2 at year 4 in 57 and 44.2 +/- 28.9 cm. at year 5 in 41 after stent insertion (p <0.001). Residual urine volume decreased after stent placement and was maintained throughout the 5-year followup (p <0.001). Mean cystometric capacity remained constant from 269 +/- 155 before insertion to 337 +/- 182 ml. 5 years later (p = 0.17). Hydronephrosis and autonomic dysreflexia improved or stabilized in most patients with functioning stents. Stent explant was necessary in 24 patients (15%), of whom 4 (16.7%) had another stent implanted. CONCLUSIONS The UroLume stent demonstrates long-term safety and efficacy for the treatment of external detrusor-sphincter dyssynergia. The outcome was similar in men with and without previous sphincterotomy.

Multicenter trial in North America of UroLume urinary sphincter prosthesis.

We investigated the effectiveness and associated complications of treatment with an endoluminal urethral sphincter prosthesis in 153 spinal cord injury men (mean age 36 years, range 16 to 74 years) with urodynamically diagnosed detrusor-external sphincter dyssynergia. These patients were prospectively treated with a urethral sphincter stent at 15 centers in North America. Followup ranged from 2 to 33 months. Voiding pressures averaged 76 +/- 28, 42 +/- 21, 44 +/- 38, 35 +/- 18 and 32 +/- 20 cm. water, respectively, before prosthesis insertion in 153 patients and at 3 months in 123, 6 months in 114, 12 months in 98 and 24 months in 22. A significant decrease in voiding pressure was noted in the 22 patients at 24 months compared with matched preoperative data (80 +/- 25 cm. water, p = 0.03). The residual urine decreased from 181 +/- 154 ml. before insertion to 82 +/- 93 ml. at 24 months (p = 0.01). Maximum cystometric capacity remained constant, with a mean of 195 +/- 158 ml. before insertion to 248 +/- 122 ml. at 24 months (p = 0.17). No significant differences were apparent after 24 months of followup in any of the urodynamic parameters between 44 patients with and 109 without previous external sphincterotomy. Hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth and soft tissue erosion did not occur. No deleterious effects were observed on renal or erectile function. Of the patients 43 (28.1%) required 2 prostheses to bridge the external sphincter completely. Stent removal was required in 10 patients. Seven explantations were required for prosthesis migration, 1 for pain and urethral edema, 1 for inability to maintain a condom catheter, and 1 for nonepithelialization and secondary bladder neck obstruction. A total of 13 patients (8.5%) required a subsequent operation for bladder neck obstruction. Therefore, the sphincter prosthesis is an attractive modality for the treatment of external sphincter dyssynergia in patients with and without previous external sphincterotomy because of its ease of deployment and minimal associated morbidity.

REMOVAL OF UROLUME ENDOPROSTHESIS: EXPERIENCE OF THE NORTH AMERICAN STUDY GROUP FOR DETRUSOR-SPHINCTER DYSSYNERGIA APPLICATION

PURPOSE We present the experience of the North American UroLume Multicenter Study Group with removal of the UroLume endoprosthesis. MATERIALS AND METHODS A total of 160 neurologically impaired patients were enrolled in the North American UroLume Multicenter Study Group for detrusor external sphincter dyssynergia application. Analysis was performed in 2 groups of patients in which the device was removed during insertion and after implantation, respectively. RESULTS Device retrieval was required during insertion in 21 patients (13%) mainly due to misplacement or migration in 17. Extraction was done with minimal complications and in all but 2 cases subsequent UroLume implantation was successful. Of 158 men with the device in place 31 (19.6%) required removal. In 34 procedures 44 devices were removed, mainly due to migration. Time from implantation to removal ranged from 4 days to 66 months (mean 22 months). The UroLume was removed en bloc in 20 cases and in parts or wire by wire in 19. The majority of patients had no or minimal complications after extraction. Only 2 patients had serious temporary complications, including bleeding and urethral injury, with no lasting consequences. No malignancy developed as a result of UroLume insertion. CONCLUSIONS While there is a potential for urethral injury and bleeding, UroLume endoprosthesis removal is largely a simple procedure with minimal complications and consequences.

Accuracy of individuals with spinal cord injury at predicting urinary tract infections based on their symptoms.

Abstract Objective: To determine whether individuals with spinal cord injuries (SCis) who complain of symptoms of a urinary tract infection (UTI) actually have a UTI. Design: A 9-month prospective case review. Participants: One hundred and forty-seven persons with SCI who presented to an outpatient urology clinic with symptoms they attributed to a UTI. Main Outcome Measures: Presence or absence of a UTI as determined by signs and symptoms of a UTI and a microscopic urine analysis (UA) for white blood cell (WBC) and bacterial colony counts. Methods: A UTI was defined as new onset of clinical signs and symptoms, significant bacterial colony counts in the urine, and evidence of tissue invasion with elevated WBC count 2:10/ high power field in the urine. Evaluation of each individual included history, physical examination, and UA with a culture and sensitivity. Evaluation for other medical problems was undertaken if history, physical examination, and laboratory results were not consistent with a UTI. Results: Sixty-one percent (90/147) of SCI persons we re accurate in predicting the presence of a UTI based on their symptoms; 39% (57 /147) were not accurate. In the group of 57 pe rsons who were not accurate in predicting whether they had a UTI, 12 persons had other medical problems including fecal impaction, bowel obstruction, dehydration, heat intolerance, glucosuria, other infectious processes, respiratory problems, and neurologic problems. The remaining 45 had bacteriuria with no pyuria. The type of bladder management did not have an impact on the accuracy of predicting the presence or absence of a UTI (P = 0 .03).

Spermatogenesis and the Pituitary-Testicular Hormone Axis in Rats During the Acute Phase of Spinal Cord Injury

Male infertility frequently occurs after spinal cord injury (SCI). However, little is known about the acute effects of SCI on male reproductive function. This study evaluated the effects of SCI on spermatogenesis and testicular-pituitary function in rats 2 and 4 weeks after injury. Spinal cord injury was produced in rats by T9 spinal cord transection. Controls received similar surgery without transection. Complete spermatogenesis was seen 2 weeks after SCI; however, abnormalities were present in the seminiferous tubules. Hormone levels were similar in the two groups. Four weeks after SCI, incomplete spermatogenesis was noted in 3 of 9 rats, 4 others had delayed spermiation, and the last 2 had nonspecific regression of seminiferous epithelium. Serum testosterone levels were lower at 4 weeks in SCI rats than in controls, but testicular testosterone content was not. Plasma gonadotropin levels were similar in the two groups 4 weeks after SCI. Quantitative analysis revealed a 26 to 33% decrease in the number of spermatogenic cells in stage VII seminiferous tubules at 4 weeks in SCI rats (p < 0.01). This study demonstrated that qualitative and quantitative impairments of spermatogenesis occur during the acute phase of SCI in rats.

Accuracy of Predicting Bladder Stones Based on Catheter Encrustation in Individuals With Spinal Cord Injury

Abstract Background: Bladder calculi are the second most common urological complication in those with spinal cord injury (SCI). Detection and removal of bladder stones are important to prevent possible complications. Objective: To determine the accuracy of bladder stone detection based on catheter encrustation in asymptomatic individuals with SCI. Design: Prospective cohort study. Methods: Cystoscopy findings in persons with SCI who were noted to have catheter encrustation at the time of catheter removal for their scheduled cystoscopy were used in this prospective study. Indwelling catheters were examined for encrustation at the time of removal as they were being prepared for cystoscopy. Cystoscopy was performed, and the presence or absence of bladder stones was noted. Main Outcome Measures: Presence or absence of bladder stones detected with cystoscopy in those with precystoscopy catheter encrustation. Results: Forty-nine individuals with indwelling catheters were evaluated. Overall, 17/49 (35%) individuals in this study had bladder stones. Catheter encrustation was noted in 13 patients. Of these 1 3 patients, 11 also had bladder stones. In other words, a positive result for catheter encrustation had a positive result for bladder stones 85% of the time. Thirty-six individuals had no catheter encrustation. Of these, 6 (16%) were found to have bladder stones. Conclusions: Encrustation of a catheter is highly predictive of the presence of bladder stones. This suggests that cystoscopy should be scheduled in a person undergoing a catheter change if catheter encrustation is noted.

Epidemiology of current treatment for sexual dysfunction in spinal cord injured men in the USA model spinal cord injury centers.

This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17-68 years (mean age = 26 +/- 17) were enrolled. Mean duration of traumatic SCI was 3 +/- 3.2 years (Range = 0.3-18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3 +/- 3.4 times per month as compared with 5 +/- 3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers.

Accuracy of bladder stone detection using abdominal x-ray after spinal cord injury.

Abstract Background: Bladder calculi are a common problern in those with spinal cord injury (SCI). Detection is important to prevent complications. Objective: To determine the accuracy of bladder stone detection by abdominal x-rays. Methods: X-ray reports from individuals with SCI with known bladder stones detected by cystoscopy were reviewed. Main outcome measures: x-ray reports noted the presence or absence of bladder stones. The stone variables evaluated were stone composition (crystallographic analysis) , widest dimension of the largest stone (during cystoscopy) , and the total volume (cm3 ) of the stone mass removed. Results: Sixty-two consecutive x-ray reports from individuals with bladder stones were reviewed. The majority of stones were calcium phosphate (46.8%) or struvite (26.7%). Regarding stone composition, the detection by x-ray was 28.6% for struvite stones and 41 .9% for calcium phosphate stones. Regarding diameter of largest stone, the detection by x-ray was 14% for stones < 0.5 cm, 0% for stones 0.5 cm to 0 .9 cm, 33% for stones 1.0 cm to 1.49 cm, 33% for stones 1.5 cm to 1.9 cm, and 54% for stones 2 2.0 cm. Regarding total volume of stones, the detection by x-ray was 0% forvolumes < 0.2 cm3 , 33% for volumes 0.2 cm3 to 0.39 cm3 , 60% for volumes 0.40 cm3 to 0.5 9 cm3 , 40% for volumes of 0.60 cm3 to 0.79 cm3 , 0% for stones from 0.8 cm3 to 0.99 cm3 , and 57% for volumes 2 1.0 cm3 . Overall, 13/ 62 (20.97%) of stones found during cystoscopy were detected by the x-ray.

Impact Of α-Blockers In Men With Spinal Cord Injury And Upper Tract Stasis

Abstract Objective: Our objective was to determine the effectiveness of α1-blockers on upper tract stasis in men with spinal cord injury (SCI) who use reflex voiding for bladder management. Methods: A retrospective chart review of men with SCI at or above T6, who used reflex voiding for bladder management and had upper tract stasis diagnosed by renal scan. Inclusion was based on the availability of the following tests both before and after α1-receptor blockade: renal scan, urodynamic studies, and arterial pressures. Part I evaluated the impact of α1-blockers on upper tract stasis. Part II evaluated the impact of α1-blockers on urodynamic parameters in those with and without resolution of stasis. Statistical methods: Chi-square test was used to determine the statistical significance of resolution of upper tract stasis. Students t test for 2-paired samples was used to evaluate whether urodynamic parameters differed significantly before and after treatment with α1-blockers. Main Outcome Measures: Urodynamic parameters evaluated included mean changes in opening pressure, maximum detrusor voiding pressure, and duration of uninhibited contraction. Results: Ten men with uppertract stasis were identified (15 renal units). After >6 months on α1-receptor antagonist therapy, upper tract stasis resolved in 8 of the 10 men (11 renal units) and persisted in 2 men (4 renal units). (P = .00026). The only urodynamic parameter that significantly changed in those with resolution of upper tract stasis was the duration of the uninhibited contraction (resolution of stasis: – 57 seconds; P < .001), persistence of stasis: +12 seconds (P < .05). No significant change in opening pressures occurred in either those with resolution of stasis or persistent stasis (P < .78). Maximum arterial pressures during voiding statistically decreased with the use of α1-blockers (152 mmHg vs 135 mmHg; P < .01). Conclusions: α1-Receptor-antagonist therapy improved uppertract stasis in men with SCI. The urodynamic parameter that changed in those with resolution of upper tract stasis was the duration of uninhibited contractions, which decreased significantly.