Prospective study of clinical, neurophysiological and urodynamic findings in multiple sclerosis patients undergoing percutaneous transluminal venous angioplasty.

OBJECTIVE: Verify whether Percutaneous Transluminal Angioplasty (PTA) may affect neural conduction properties in Multiple Sclerosis (MS) patients, thereby modifying patients' disability, with prospective neurophysiological, urodynamic, clinical and subjective well-being evaluations. METHODS: In 55 out of 72 consecutively screened MS patients, the following procedures were carried out before (T0), at 2-6 months (T1) and at 6-15 months (T2) after a diagnostic phlebography, eventually followed by the PTA intervention if chronic cerebrospinal venous insufficiency (CCSVI) was diagnosed: clinical/objective evaluation (Expanded Disability Status Scale, EDSS), ratings of subjective well-being, evaluation of urodynamic functions and multimodal EPs (visual, acoustic, upper and lower limbs somatosensory and motor evoked potentials). RESULTS: The number of dropouts was relatively high, and a complete set of neurophysiological and clinical data remained available for 37 patients (19 for urological investigations). The subjective well-being score significantly increased at T1 and returned close to basal values at T2, but their degree of objective disability did not change. Nevertheless, global EP-scores (indexing the impairment in conductivity of central pathways in multiple functional domains) significantly increased from T0 (7.9 ±â€¯6.0) to T1 (9.2 ±â€¯6.3) and from T0 to T2 (9.8 ±â€¯6.3), but not from T1 and T2 (p > 0.05). Neurogenic urological lower tract dysfunctions slightly increased throughout the study. CONCLUSIONS: The PTA intervention did not induce significant changes in disability in the present cohort of MS patients, in line with recent evidence of clinical inefficacy of this procedure. SIGNIFICANCE: Absence of multimodal neurophysiological and functional testing changes in the first 15 months following PTA suggests that conduction properties of neural pathways are unaffected by PTA. Current findings suggest that the short-lived (2-6 months), post-PTA, beneficial effect on subjective well-being measures experienced by MS patients is likely related to a placebo effect.

Perineal schwannoma: an unusual tumor and clinical presentation - first case with erectile dysfunction associated with this neoplasm.

INTRODUCTION: Perineal schwannomas (PS) are very rare benign tumors with few cases reported in literature and none of these reports erectile dysfunction among clinical presentations. CASE DESCRIPTION: We report a case of PS with unusual clinical presentation showing erectile dysfunction associated with perineal pain and discomfort during defecation, and the postoperative residual pain and erectile dysfunction treatment. CONCLUSIONS: On the basis of a literature review of all cases reported and on our case reported, we have delineated a clinical, diagnostic, and therapeutic profile of PS, summarized in a useful table.

Post-traumatic acute-on-chronic subdural haematoma: an unusual presentation of skull metastasis from prostate carcinoma.

The authors report on a case of an 80-year-old man operated on urgently for evacuation of an acute-on-chronic subdural haematoma after a minor blunt head trauma that had occurred the day before. The haematoma was revealed by a plain CT scan on arrival at the accident and emergency department. During operation, the calvarial bone and dura mater were found to be of pathological aspect and histology subsequently confirmed metastatic involvement from a known primary prostate cancer (PC). After an initial successful technical and clinical result, the patient worsened again due to a rebleed and succumbed soon after. The awareness of the possibility of osteodural metastatic involvement could have led to the adjunct of a contrast-enhanced CT study and altered the treatment strategy.

Human papillomavirus-related basaloid squamous cell carcinoma of the bladder associated with genital tract human papillomavirus infection.

Basaloid squamous cell carcinoma is a biologically aggressive neoplasm mainly found in the head and neck region. Recently, four cases of basaloid squamous cell carcinoma of the bladder have been reported, and three of them occurred in patients with neurogenic bladder, repeated catheterizations and human papillomavirus infection of the urinary tract. To the best of our knowledge, none of the patients affected by basaloid squamous cell carcinoma of the bladder described in the literature had documented genital involvement by human papillomavirus. Herein, we describe the case of a woman with neurogenic bladder affected by basaloid squamous cell carcinoma of the bladder and by a concomitant genital tract human papillomavirus infection.

Ten-year follow-up of sildenafil use in spinal cord-injured patients with erectile dysfunction.

INTRODUCTION: Data are sparse concerning the long-term effects of phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction (ED). AIM: To evaluate the efficacy and safety of long-term sildenafil use in subjects with ED caused by spinal cord injury (SCI). METHODS: Phase 1: From October 1998 to January 1999, 113 SCI patients with ED were given 50 mg of sildenafil after a 4-week treatment-free period. Those with a score lower than 26 on the International Index of Erectile Function (IIEF-15) and with less than 75% total successful sexual attempts the dosage of sildenafil was increased to 100 mg. Attempts were evaluated using the Sexual Encounter Profile Questions 2 and 3 (SEP2 and 3) regarding respectively the capacity to penetrate their partner and to maintain the erection after penetration. Phase 2: Only responding patients entered phase 2 where they were evaluated every 6 months. The final visit was concluded by January 2009. MAIN OUTCOME MEASURES: Follow-up using the IIEF-15 questionnaire every 6 months. RESULTS: Seventy-five patients entered Phase 2. Thirty-eight patients were excluded, 35 of them because they did not respond to the drug. Lesions higher than T12, an incompleteness of lesions, and higher residual erection were significant predictable factors for the success of the therapy (P < 0.05). Phase 2: the most frequent reason (68.3%) for discontinuing treatment was the desire to try a new oral therapy especially for patients using 100 mg. Thirty-four individuals continued treatment, 28 of whom took 50 mg. CONCLUSION: Sildenafil represents an effective and safe long-term option for SCI subjects with ED. Further investigation of long-term use of oral PDE5 inhibitors in SCI patients is needed for evaluating both factors that are determinant in the choice of a starter treatment and in detecting elements that influence the switching from initial treatment.

Ten years of phosphodiesterase type 5 inhibitors in spinal cord injured patients.

INTRODUCTION: The majority of men with spinal cord injury (SCI) require chronic treatment for erectile dysfunction (ED), but most of them, prior to taking phosphodiesterase type 5 (PDE5) inhibitors, stopped therapy due to side-effects or low compliance rate. AIM: Analysis of literature on oral PDE5 inhibitors in individuals with SCI and ED in order to evaluate how much their release changed the management of ED in SCI subjects and what remains to be seen of their potential or limits. MAIN OUTCOME MEASURES: Questionnaires on sexual function. METHODS: 18 internationally published clinical studies that enrolled SCI males treated with at least one of the PDE5 inhibitors were analyzed. RESULTS: The small numbers of papers with large and diverse outcome measures did not consent a meta-analysis of treatment results. 705 used sildenafil, 305 vardenafil and 224 tadalafil. Median age was less than 40 years. Only 1 study excluded tetraplegic individuals. For measures of ED evaluated, 11 out of 13 studies reported a significant statistical improvement with PDE5 inhibitors versus placebo or erectile baseline (P < 0.01, or p < 0.005). The most frequent predicable factor for the therapeutic success of PDE5 inhibitors was upper motoneuron lesion. Statistical impact on ejaculation success rates was shown in at least one paper for all PDE5 inhibitors (p < 0.05). Overall, 15 patients, (7 using sildenafil), discontinued the therapies due to drawbacks. Only 1 sildenafil study reported a follow-up maximum of 24 months. CONCLUSIONS: Literature suggests that all oral PDE5 inhibitors represent a safe and effective treatment option for ED caused by SCI. Further research is needed on head-to-head comparative trials and SCI patient preference for these drugs; their impact on ejaculation and orgasm function, their early use after SCI for increasing the recovery rate of a spontaneous erection, and their effectiveness and tolerability in the long-term are still to be investigated.

Efficacy and safety of medium and long-term tadalafil use in spinal cord patients with erectile dysfunction.

INTRODUCTION: The efficacy of phosphodiesterase type 5 inhibitors for a broad spectrum of erectile dysfunction (ED) is largely reported in literature. Data are lacking concerning medium and long-term effects and safety of these treatments. AIM: The aim of this study was to evaluate the efficacy and safety of medium and long-term use of tadalafil in subjects with ED because of spinal cord injury (SCI). METHODS: Phase 1: From March 2003 to March 2007, 103 SCI patients with ED, mean age 39 years, were given 10 mg of tadalafil after a 4-week treatment-free period. For patients with a score lower than 26 in the erectile domain of the International Index of Erectile Function (IIEF15) and with total unsuccessful sexual attempts of more than 25% according to the Sexual Encounter Profile questions 2 and 3 (SEP2-3), the dosage of tadalafil was increased to 20 mg. Phase 2: Only responding patients entered phase 2 where the subjects were evaluated in office visits every 6 months using the IIEF15 questionnaire and a diary reporting the day and time the drug was taken. All final visits were concluded by May 2008. MAIN OUTCOME MEASURES: The improvement of ED was measured using the IIEF15 and the SEP2-3 questions. RESULTS: Twenty-nine patients were excluded from phase 2: Twenty-seven did not respond to the drug and two left the study because of mild drawbacks. During the 6-month follow-up, nine left the study. Sixty-five individuals continued treatment with median follow-up of 33.6 months, 31 of whom took 10 mg and 34 who used 20 mg. Each group maintained up until the final visit a significant statistical improvement in erectile function, sexual satisfaction, overall satisfaction and percentages of "yes" responses to the SEP2-3 compared with baseline using the Wilcoxon test (P < 0.05). CONCLUSION: Tadalafil represents an effective and safe long-term option for SCI patients with ED.

Neurogenic detrusor overactivity treated with english botulinum toxin a: 8-year experience of one single centre.

OBJECTIVE: Determine long-term effect of English botulinum neurotoxin type A (BoNTA; Dysport) for refractory neurogenic detrusor overactivity (NDO) for possible reduction of BoNTA efficacy after repeated injections. METHODS: Between 1999 and 2005, 199 patients with spinal cord lesions with refractory NDO were treated with Dysport. All patients underwent a clinical examination, urinalysis, and videourodynamic study at baseline and at 3, 6, and 12 mo after each treatment, as well as a visual analogue scale (VAS) assessment and a bladder diary checked for 1 wk before each visit. We used 1000, 750, 500 IU BoNTA at the beginning of our experience, and thereafter we mainly used 750 IU. Outcome measures included frequency of urge urinary incontinence (Incontinence Episode Frequency [IEF] test); urodynamic parameters including maximum cystometric bladder capacity (MCBC), reflex volume (RV), bladder compliance (BC); number of pads/condoms; antimuscarinic drug consumption; short- and long-term side-effects; and quality of life measured with VAS. RESULTS: No statistically significant differences were found in efficacy duration with the three Dysport doses (p=0.5274). The difference between the intervals of injections was not statistically significant (p=0.2659). MCBC, RV, and BC improved significantly after treatment compared with baseline values (p<0.001) and there were no statistically significant differences after each retreatment or regarding Dysport dose (p>0.05). There was a significant improvement in patient satisfaction after each retreatment as expressed on the VAS (p<0.001). There was a significant reduction in IEF score and pads/condoms use in the first 4 wk after each treatment (p<0.0001). CONCLUSION: After repeated injections the effect of BoNTA remained constant.

Pharmacologic treatment in postprostatectomy stress urinary incontinence.

OBJECTIVES: The aim of this study was to assess efficacy and safety of association of duloxetine and rehabilitation compared with rehabilitation alone in men with SUI after radical retropubic prostatectomy (RRP), and to compare continence rate even after planned duloxetine suspension. METHODS: After catheter removal, 112 patients were randomized to receive rehabilitation and duloxetine (group A) or rehabilitation alone (group B), for 16 wk. INCLUSION CRITERIA: postprostatectomy SUI with daily incontinent episodes frequency (IEF) of four or greater. After 16 wk both groups suspended duloxetine/placebo and continued rehabilitation. All patients completed incontinence quality of life (I-QoL) questionnaire and bladder diary. Wilcoxon test was used to analyse changes in IEF and in I-QoL score; Fisher exact test was used to compare continent patients between the groups. RESULTS: Adverse events for duloxetine was 15.2%. 102 men completed the study. There was a significant decrease in pad use in group A. After 16 wk, 39 patients versus 27 were dry (p=0.007). At 20 wk, 4 wk after planned interruption of duloxetine, we observed a U-turn, 23 patients were completely dry in group A versus 38 in group B (p=0.008). Whereas, after 24 wk, 31 in group A versus 41 in group B were dry (p=0.08). The decrease in IEF and improvements in I-QoL scores were significantly greater in group A for the first 16 wk. CONCLUSIONS: The data suggest that combination therapy might provide another treatment option for SUI in men that might increase the percentage of early postsurgery continence.

Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence.

PURPOSE: Urinary incontinence after radical prostatectomy is a significant clinical problem. In this prospective study we investigate the effectiveness of early pelvic floor muscle training (PFMT) on a large population, that had undergone radical retropubic prostatectomy (RRP) at our department. METHODS: 300 consecutive patients who had undergone RRP for clinically confined prostate cancer were randomized in two groups after catheter removal. One group of 150 patients took part in a structured PFMT program. This began before discharge and consisted of Kegel exercises. The remaining 150 patients constituted the control group, they were not formally instructed in PFMT. Incontinence was assessed objectively using the 1 hour and 24 hour pad test, as well as with the ICS-Male questionnaire. All patients who were incontinent after 6 months underwent urodynamic evaluation. RESULTS: In the treated group, 19% (29 patients) achieved continence after 1 month, and 94.6% (146 patients) after 6 months. In the control group 8% (12 patients) achieved continence after 1 month, and 65% (97 patients) after 6 months (p<0.001). Patient age did not correlate with continence in the control group (p>0.05), although a significant correlation was revealed within the treated group (p<0.01). Overall, 93.3% of the total population achieved continence after one year. CONCLUSIONS: After RRP an early supportive rehabilitation program like PFMT significantly reduces continence recovery time.