Transanal Irrigation for Neurogenic Bowel Dysfunction in Multiple Sclerosis: A Retrospective Study.

Background/Aims: Sixty-eight percent of multiple sclerosis (MS) patients suffer from neurogenic bowel dysfunction (NBD). Transanal irrigation (TAI) is part of the therapeutic strategy. This retrospective study aims to assess the efficacy of TAI in MS population. Methods: Twenty-eight MS patients who underwent TAI after a learning period were included. We collected several demographic data: MS disease characteristics, treatments, urinary and bowel dysfunction characteristics, urodynamic parameters, results of the NBD score, the Urinary Symptom Profile (USP) score, and the Patient Global Impression of Severity score, completed by patients before the learning and during the follow-up consultation. We defined 4 specific groups depending on the NBD score severity: very minor, minor, moderate, and severe. Results: Mean follow-up was 124 days, 85.0% were initially constipated and 36% had fecal incontinence. After TAI, improvement of NBD score was higher in initial Moderate NBD score group with 75.0% of patients decreasing their NBD score into lower severity categories. Few modifications were observed for baseline Very minor and Severe NBD score groups with 60.0% and 87.5% of patients staying in the same category. Statistical improvement of USP voiding dysfunction score was observed (95% CI, -6.13--1.19; P = 0.005) without improvement of overactive bladder USP sub-score. Conclusions: TAI is effective in NBD, especially in MS patients with initial Moderate NBD score. Improvement of voiding dysfunction following TAI confirms the pelvic organ cross-talk and the need to systematically consider and treat bowel dysfunction in MS to also improve urinary symptoms.

External Anal Sphincter Fatigability: An Electromyographic and Manometric Study in Patients With Anorectal Disorders.

BACKGROUND/AIMS: External anal sphincter (EAS) plays an important role in fecal and gas voluntary continence. Like every muscle, it can be affected by repeated efforts due to fatigability (physiological response) and/or fatigue (pathological response). No standardized fatiguing protocol and measure method to assess EAS fatigability has existed. The aim is to test a simple, standardized protocol for fatiguing and measuring EAS fatigability and fatigue to understand better the part of EAS fatigability in the pathophysiology of fecal incontinence. METHODS: Patients with anorectal disorders evaluated with anorectal manometry were included. They had to perform 10 repetitions of maximum voluntary contraction (MVC) of 20 seconds. Measurement was made with an anorectal manometry catheter and a surface recording electromyography (EMG). The primary outcome was the difference in EMG root mean square between the first and the last MVC. Secondary outcomes were differences in other EMG and manometry parameters between the first and the last MVC. Difficulties and adverse effects were recorded. RESULTS: Nineteen patients underwent the fatiguing protocol. All patients completed the entire protocol and no complications were found. No difficulty was declared by the examiner. A significant decrease in root mean square was found between the first and last MVC (0.01020 ± 0.00834 mV vs 0.00661 ± 0.00587 mV; P = 0.002), in maximum anal pressure area under the curve of continuous recordings of anal pressure and mean and total EMG power (P < 0.05). CONCLUSIONS: This protocol is simple and minimally invasive to measure EAS fatigue and fatigability. We highlighted a fatigue of EAS in many patients with anorectal disorders.

Effect of a strong desire to void on walking speed in individuals with multiple sclerosis and urinary disorders.

BACKGROUND: Lower urinary tract symptoms, especially overactive bladder, are frequent and disabling in individuals with multiple sclerosis (IwMS). An association with gait disorders is common, which could aggravate continence difficulties and affect quality of life. The association between the need to void and walking has never been studied in this population. OBJECTIVE: The primary aim of this study was to assess the effect of a strong desire to void (SDV) on walking speed in IwMS and lower urinary tract symptoms. The secondary aim was to identify clinical or urodynamic factors associated with walking speed impairment at SDV in this population. METHODS: We included IwMS with urinary disorders and Expanded Disability Status Scale score<7 in this observational study. Individuals underwent 3 10-m walk tests (10MWT) and one Timed Up and Go (TUG) test at SDV and at post-void (PV). RESULTS: Among the 72 IwMS included (mean [SD] age 50.6 [11.6] years; 46 [64%] females), the mean (SD) speed for 10MWT was 1.00 (0.31) m.s-1 at SDV and 1.07 (0.30) m.s-1 at PV (P<0.0001). Time for TUG was also increased when individuals felt SDV: mean 11.53 (4.6) sec at SDV versus 10.77 (3.8) sec at PV (P=0.004). No predictors of greater impairment of walking speed at SDV were identified. CONCLUSION: This study suggests a clinical impact of bladder sensation on walking speed in IwMS and urinary disorders. None of the individual characteristics could predict greater decrease in gait velocity at SDV.

What criteria affect a patient's choice of catheter for self-catheterization?

AIM: The aim was to determine which criteria are most influential in guiding the patient's choice of catheter during clean intermittent self-catheterization (CISC) education. METHODS: A questionnaire exploring five traits (catheter design, catheter length, the comfort of use, nurse's explanations, and how easy it was to carry and dispose of the catheter) was administered to all patients who succeeded in performing CISC. The patients had to report the criterion that most influenced their choice, and rate the importance of each criterion from 1 to 4 on a Likert scale (strongly disagree, somewhat disagree, somewhat agree, strongly agree). The study assessed the impact that age, sex, etiology, dependency, motor or sensory upper limb deficiency, and position required to perform CISC may have had on the importance of the different criteria. RESULTS: Seventy-three patients were included (mean age, 50.9 ± 14.3 years). The most important criterion was the nurse's explanations (44%), followed by comfort of handling (32%), the discreet aspect of carrying the catheter (15%), and catheter length (7%). The esthetic aspect was not important for 34% of patients, whereas all the other criteria were important for at least 82% of patients. The comfort of handling was more often a priority for those with motor or sensory upper limb disorders (P < .01). The other characteristics of the patients did not impact the way they prioritized the criteria. CONCLUSION: These results highlight the importance of extensive training for nurses involved in CISC education, as their explanations have the greatest impact on the patient's choice of the catheter.

Use of a specific questionnaire and perineal electromyography to assess neuropathic pain after radical retropubic prostatectomy.

OBJECTIVE: Prostate cancer is the most frequent cancer in men and radical retropubic prostatectomy (RRP) is one of the first-line treatment. However, RRP has some side effects and can lead to chronic perineal pain. The objective of the study was to determine in patients suffering from perineal pain after RRP the possibility of a neurogenic damage by means of a specific questionnaire dedicated to track down neuropathic pain. METHODS: Forty patients were explored by a specific and validated questionnaire, the Neuropathic Pain Symptom Inventory (NPSI). Patients were divided into two groups: Group A with an NSPI score ≥4 was considered as suffering from neuropathic pain, and Group B was considered as a control group without neuropathic pain (NSPI score <4). All patients had a perineal electrophysiological testing to confirm the possibility of a neurogenic damage. RESULTS: Group A was composed by 13 men and Group B by 27 men, with mean age 72.45 years and mean duration of pain 2.7 years. In Group A, the most frequent symptoms were burning sensation, electrical shock and numbness. Location of the pain was global perineal area (8/13), anus (10/13), penis (5/13) and glans penis (2/13). Electromyography (EMG) findings confirmed the presence of denervation and neurogenic damages compared with controls (p < 0.001). CONCLUSION: One third of the patients consulting for chronic pain following RRP had probably a neuropathic lesion leading to a chronic perineal pain as suggested by an NSPI score ≥ 4 and EMG alterations.

Influence of the urine stream interruption exercise on micturition.

OBJECTIVES: To assess the effect of urine stream interruption exercise on micturition. METHODS: This study was conducted prospectively in female patients without urinary disorders. Two uroflowmetries were performed: one during a usual micturition and one during an exercise of urine stream interruption. For the urine stream interruption exercise the subject was asked to begin the micturition, to stop it at 3 s, when the stream is interrupted, to start voiding again, then again stop it at 3 s and repeat this manoeuvre until the end of the micturition. RESULTS: Twenty female patients (mean age 38.7 years old, SD 12.3) were included. Post void residual volume was higher after the urine stream interruption micturition (mean 36.7 mL, SD 46.6) than during standard micturition (mean 8.2 mL, SD 24.1) (P = 0.02). During normal voiding, the maximal flow rate was higher (26.9 mL/min vs 17.8 mL/min; P < 0.0001). There was no difference concerning neither the voiding volume nor the slope of ascending part of flow curve. During urine stream interruption micturition, the flow rate slope, the voiding volume and the maximal flow rate by voiding sequence were decreasing as the voiding sequences followed each other. CONCLUSIONS: Urine stream interruption increases the post-void residual volume and translates into less efficient micturition. Thus, it should not be used in current practice of pelvic floor muscles training.

Urethro-vaginal reflux during micturition: An underestimated cause of urinary incontinence in adult women.

AIMS: To evaluate if urethrovaginal reflux (UVR) is an underestimated cause of insensible or postmicturition incontinence in adult women. METHODS: An observational and retrospective study was carried out on the computerized records of a neuro-urology department. Female patients who had insensible or postmicturition incontinence were investigated. Retrograde and voiding urethrocystography (UCG), urodynamic evaluation, urethral pressure profilometry, and anamnestic and clinical examination had to be available. RESULTS: Among the 79 adult female patients with insensible or postmicturition incontinence in whom the whole set of required evaluations was achieved, 16 had a UVR (mean age 47 ± 15 years). There were no urethral diverticula, urethrocele, vesicovaginal, or urethrovaginal fistula on their UCG. All of them also had a cystoscopy and a CT urography which did not establish any abnormality. CONCLUSIONS: UVR is not an exclusive pathology of children. This mechanism seems to be an underestimated cause of urinary incontinence in adult women. Retrograde and voiding UCG appears to be the gold standard to confirm the intravaginal reflux.

Urological dysfunction in patients with hereditary spastic paraplegia.

AIMS: Purposes of this study were to describe lower urinary tract symptoms (LUTS) and related urodynamic patterns in patients with hereditary spastic paraplegia (HSP), and to characterize LUTS management and associated uronephrological complications. METHODS: We retrospectively reviewed medical files of HSP patients, consecutively followed in our Physical and Rehabilitation Medicine Department between 1999 and 2016. Clinical, urodynamic, and radiological data were collected and analyzed. Different treatments which have been prescribed and uronephrological complications were also recorded. Patients with other neurological or urological diseases were excluded. RESULTS: Thirty-three patients with HSP were included. Mean duration of follow-up was 8.1 ± 5 years, mean age 62 ± 14 years, and 70% were men. The most frequent LUTS was urgency and voiding dysfunction (both 69.7%). Incontinence and retention with a significant postvoid residue above 100 mL accounted for 66.7% and 57.6% of initial symptoms respectively. Neurogenic detrusor overactivity was diagnosed in 80.7% of patients. Two-thirds of our cohort were treated with anticholinergics and 9.1% required intradetrusor botulinum-toxin injections. Only 27.3% of patients performed clean intermittent self-catheterization. Febrile urinary tract infections (21.2%), urolithiasis (15,1%), hydronephrosis (6%), and chronic renal failure (9.1%) were found. CONCLUSION: Given their high prevalence and the risk of uronephrological complications, LUTS should be systematically assessed in HSP patients. The systematic screening of urological dysfunction in this population would improve its management, decrease the incidence of uronephrological complications, and increase the quality of life.

Effect of radical prostatectomy on involuntary pelvic floor muscle contraction.

AIMS: Radical prostatectomy may cause stress urinary incontinence (SUI). We compared continent and incontinent men after radical prostatectomy, in regard to the change of the temporal pattern of pelvic floor activation during cough. METHODS: Twenty-two patients were included in this prospective, multicentric study. All patients gave their informed consent. Simultaneous recordings of electromyographic activity of external anal sphincter (EAS EMG) and external intercostal muscle (EIC EMG) during cough were performed with a pair of pregelled surface electrodes. Cough effort caused an involuntary pelvic contraction. Intercostal muscles recording was chosen because they are one of the muscular components of cough initiation with diaphragm muscle. Twenty-four-hour pad-weighing test was used to quantify urinary incontinence. The primary endpoint was the latency between the onset of EIC EMG and EAS EMG (RT3), during a cough effort. We also measured the contraction time, the maximum EAS EMG activity, and the area under the curve. RESULTS: All the patients were analyzed: 12 continent and 10 with SUI. The median age was 66 years old. Both groups were similar except in term of follow-up. Median latency was increased by -1.7 ms (-47.9; +34.2) to 55.8 ms (+47.5; +80) in patients with SUI (P = 0.0033; Table 2). The duration of the contraction, the maximum EAS EMG activity and the area under the curve were not different. CONCLUSIONS: The latency between the onset of EIC EMG and EAS EMG is increased in patients with SUI after radical prostatectomy. It may be one of the reasons for SUI in these patients.

Diffusion-Weighted Magnetic Resonance Imaging: A New Tool for the Diagnosis of Bladder Pain Syndrome/Interstitial Cystitis.

OBJECTIVES: To determine whether diffusion-weighted magnetic resonance imaging (DWMRI), a noninvasive procedure, can contribute to the diagnosis of bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS: The pelvic DWMRI of patients with chronic pelvic pain syndrome was selected between January 2012 and June 2017. A radiologist analyzed the bladder wall signal; he was blinded to the patients' clinical data. According to the 2008 European Society for the Study of Bladder Pain Syndrome/Interstitial Cystitis criteria, 2 groups of patients were determined: BPS/IC and no BPS/IC. The association between BPS/IC and the wall signal intensity was compared. RESULTS: In the 106 patients included, 82 had criteria for BPS/IC and 24 did not. A significant difference in the distribution of the signal was found between the 2 groups (p = 0.01). High signal intensity of the bladder wall was related to the presence of a BPS/IC with a sensitivity of 28% and a specificity of 88%. No signal intensity of the bladder wall was related to the absence of a BPS/IC with a sensitivity of 96% and a specificity of 29%. CONCLUSIONS: In -DWMRI, high bladder wall signal intensity helps to affirm a BPS/IC, whereas the absence of signal helps to exclude the diagnosis. Further studies are needed to confirm these preliminary results.

Lower urinary tract symptoms treatment constraints assessment (LUTS-TCA): a new tool for a global evaluation of neurogenic bladder treatments.

OBJECTIVES: To develop a new tool to assess constraints due to urinary treatments in neurological patients. MATERIALS AND METHODS: A prospective, monocentric study has been conducted from January to May 2017. Out-patients (multiple sclerosis, spinal cord injury, Parkinson disease) were included in a referral center if they had LUTS treatment for at least 3 months. To validate psychometric properties, we conducted a literature review, qualitative interviews, and discussion with a panel of six experts. Comprehension, acceptation, and pertinence were tested by a pilot study. A validation study, designed to calculate content validity, internal consistency reliability, and test-retest reliability [intraclass correlation coefficient (ICC)] has been conducted. The primary outcome was good psychometric properties defined with Cronbach's α > 0.7 and ICC > 0.7. RESULTS: Comprehension, acceptation, and pertinence were excellent. Validation study showed a perfect content validity (r2 = 1) and excellent internal consistency reliability (Cronbach' α = 0.90). Total score was between 0 (best score) to 66 (maximal constraints). Test-retest reliability calculated using ICC was 0.81. Time to fill questionnaire was 4 min 20 s. The final version was composed by 22 items. CONCLUSION: LUTS TCA is the first validated tool to assess constraints of urinary treatment and has excellent psychometric properties.

Specificity of Lower Urinary Tract Symptoms in Neuromyelitis Optica in Comparison With Multiple Sclerosis Patients.

PURPOSE: The aim of this study was to describe lower urinary tract symptoms in neuromyelitis optica (NMO), and to compare these data with urinary disorders observed in multiple sclerosis (MS) patients. METHODS: Retrospective study of data collected from January 1997 to July 2017 using the database from a Neuro-Urology Department of a university hospital. NMO and MS patients were matched for sex, age, and Expanded Disability Status Scale (EDSS). RESULTS: Twenty-six patients with NMO were included and compared with 33 MS patients. Mean age was 41.6 years (standard deviation [SD], 14,8), mostly female patients (24 vs. 2 males). Mean EDSS was 4.6 (SD, 1.8) in the 2 groups. In NMO group, 57% of the patients (n=15) had overactive bladder with urgency and urge incontinence and 38.5% (n=10) of them had nocturia. Voiding symptoms was observed in 69.2% of the patients (n=18); 42.3% of NMO patients performed self-intermittent catheterization versus 12.1% in MS patients (P=0.012). Low bladder compliance and severe urinary tract infections (pyelonephritis) were more frequent in NMO than in MS patients (respectively 15% vs. 0%, P=0.016 and 42% vs. 12%, P=0.024). CONCLUSION: Lower urinary tract symptoms, especially overactive bladder and urinary retention, are frequent in NMO. Low bladder compliance, serious urinary infections, and high prevalence of urinary retention requiring self-intermittent catheterization are the main symptoms significantly more frequent than in MS.

Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies.

BACKGROUND: Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject. OBJECTIVE: This article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed. METHODS: We performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date. RESULTS: We selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it. CONCLUSION: Pelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.

Adherence to Anticholinergic Therapy and Clean Intermittent Self-Catheterization in Patients With Multiple Sclerosis.

PURPOSE: To evaluate adherence to anticholinergic therapy (AT) and clean intermittent self-catheterization (CISC) in patients with multiple sclerosis (MS) and to identify factors associated with poor adherence. METHODS: This single-center study prospectively included 49 patients suffering from MS who had been prescribed AT and/or CISC. Adherence was evaluated using a self-report questionnaire. The Expanded Disability Status Scale (EDSS), Patient Global Impression of Improvement, Mini-Mental State Examination, Urinary Symptom Profile, and Hospital Anxiety and Depression (HAD) instruments were administered, and the number of daily anticholinergic pills and/or catheterizations was noted. Whether patients were receiving concomitant intradetrusor botulinum toxin injections was assessed, as were barriers to treatment, side effects, number of spontaneous micturitions, reasons for the prescription, satisfaction, and difficulties. RESULTS: Only 38% of patients were adherent to AT. Experiencing side effects was related to nonadherence (P=0.02). Only 29% of patients were adherent to CISC. More intense voiding dysfunction (P<0.001), a higher frequency of CISC (P=0.03), and a higher EDSS score (P=0.02) were associated with better adherence. Conversely, the HAD score (P<0.001), depression (P<0.001), the persistence of spontaneous micturition (P<0.001), a blocking sensation during catheterization (P=0.04), and the need to adapt one's posture or gesture to perform catheterization (P=0.04) were associated with poorer adherence. CONCLUSIONS: Adherence to AT and CISC was poor in patients with MS suffering from bladder dysfunction. Several factors related to nonadherence were identified in this study, and addressing these factors might help to improve treatment adherence.

Intermittent Catheterization Adherence Scale (ICAS): A new tool for the evaluation of patient adherence with clean intermittent self-catheterization.

AIM: Patients who have successfully acquired the intermittent self-catheterization (ISC) technique can be expected to use it on a long-term basis. The aim of the present study is to present a validated evaluation scale, referred to as the ICAS (Intermittent Catheterization Adherence Scale), which can be used to assess long-term patient adherence to prescribed ISC treatment. METHODS: The scale was validated in neurologic and non neurologic patients in an experienced French neurourology center, between September 2014 and February 2016. Eight items were chosen, providing a relatively objective insight into the degree to which patients reduce the frequency of their ISC procedures. Various factors, including the patients' understanding of the procedure, its relevance to their specific condition, as well as their acceptance of its psychological and inherently time-consuming drawbacks, were evaluated. The ISC construct validity and reproducibility, based on internal test-retest consistency and test-retest reliability, were measured using the Intra-class Correlation Coefficient (ICC). RESULTS: The ICAS was validated in 222 patients (133 females, 89 males, mean age 53 ± 11 years). The patients' comprehension of the questions was found to be good, and the questionnaire was well accepted. Cronbach's alpha was 0.73. The ICC test-retest consistency was also found to be good. CONCLUSION: The ICAS is a simple, acceptable, valid and reproducible test, and in some cases it may facilitate the medical follow-up of ISC patients. In the clinical environment, it is found to be a valuable tool, which can assist medical staff in the prevention of complications related to ISC non-compliance.

Lower Urinary Tract Symptoms in Elderly Population With Multiple Sclerosis.

PURPOSE: The aim of this study is to compare the clinical and urodynamic characteristics of urinary disorders in multiple sclerosis (MS) patients in a geriatric population with a nongeriatric population. METHODS: This study was conducted retrospectively between 2010 and 2016. Each patient with MS aged 65 and older was matched with 2 patients with MS aged less than 65 in sex, form of MS, and Expended Disability Status Scale (EDSS). Demographic data, urinary symptoms, treatment, quality of life, repercussion of lower urinary tract symptoms on daily life activities and psychological state and urodynamic parameters were collected. Differences between the 2 populations were evaluated using Student test, chi-square, or Fischer tests. RESULTS: Twenty-four patients with MS aged 65 and older (mean age, 69.8 years) were matched with 48 patients aged less than 65 years (mean age, 49.4 years). Maximum urethral closure pressure was lower in the elderly population than in the nongeriatric population (mean±standard deviation [SD]: 35.6±18.5 cm H2O vs. 78.2±52.3 cm H2O, P<0.001). In the male population, there was no statistical difference in any other clinical or urodynamic endpoints. In the female population, voiding symptoms was more described in the nongeriatric population (Urinary Symptom Profile low stream: 3.4±3.5 vs. 1.7±2.4, P=0.04), geriatric population had less urinary treatment (P=0.05). LUTS had less impact on quality of life (Qualiveen: 1.4±1.0 vs. 2.1±0.9, P=0.02) on the geriatric population than in the nongeriatric of female MS patients. CONCLUSIONS: Geriatric population of MS has few differences of urinary disorders compared to a nongeriatric population with EDSS, sex, and MS form equal. However, the psychological impact of these urinary disorders is less important in female geriatric population.

Diagnosis and clinical evaluation of neurogenic bladder.

Neurologic diseases lead to urinary dysfunctions. The aim of this article was to present an overview of diagnosis and evaluation of neurogenic bladder with a special focus on urodynamic tests. Overactive bladder, with high detrusor pressure associated with detrusor sphincter dyssynergia, can lead to severe complications with renal failure, upper urinary tract dilatation and infectious complications. Underactive bladder with voiding dysfunction and urinary retention, is also a risk factor of urological alterations. Full clinical examinations, including urodynamics and selective radiographic imaging studies, are essential to best manage these patients.