Neurogenic Lower Urinary Tract Dysfunction in Asymptomatic Patients with Multiple Sclerosis.

Neurogenic lower urinary tract dysfunction (NLUTD) in asymptomatic patients with MS has been described in preliminary studies, but specific investigations of this topic are rare. Many authors advise early diagnosis and treatment of NLUTD in patients with MS. In contrast, clinical practice and different guidelines recommend neuro-urological diagnostics only in the presence of symptoms. Our aim was to investigate the characteristics of NLUTD and the correlations of clinical parameters with NLUTD in asymptomatic patients with MS. We evaluated bladder diaries, urodynamic findings, and therapy proposals. Correlations of the voided volume, voiding frequency, urinary tract infections, and uroflowmetry including post-void residual with the urodynamic findings were determined. In our study, 26% of the patients were asymptomatic. Of these, 73.7% had urodynamic findings indicative of NLUTD, 21.1% had detrusor overactivity, 13.2% had detrusor underactivity, 13.2% detrusor overactivity and detrusor sphincter dyssynergia, and 57.9% had radiologically abnormal findings of the bladder. No patients presented low bladder compliance or renal reflux. Clinical parameters from the bladder diary and urinary tract infections were found to be correlated with NLUTD, and the absence of symptoms did not exclude NLUTD in patients with MS. We observed that urinary tract damage is already present in a relevant proportion. Based on our results, we recommend that patients with MS be screened for NLUTD regardless of the subjective presence of urinary symptoms or the disease stage.

Clinical Predictors of Neurogenic Lower Urinary Tract Dysfunction in Persons with Multiple Sclerosis.

BACKGROUND: Multiple sclerosis patients often develop neurogenic lower urinary tract dysfunction with a potential risk of upper urinary tract damage. Diagnostic tools are urodynamics, bladder diary, uroflowmetry, and post-void residual, but recommendations for their use are controversial. OBJECTIVE: We aimed to identify clinical parameters indicative of neurogenic lower urinary tract dysfunction in multiple sclerosis patients. METHODS: 207 patients were prospectively assessed independent of the presence of lower urinary tract symptoms. We analyzed Expanded Disability Status Scale scores, uroflowmetry, post-void residual, rate of urinary tract infections, standardized voiding frequency, and voided volume in correlation with urodynamic findings. RESULTS: We found a significant correlation between post-void residual (odds ratio (OR) 4.17, confidence interval (CI) 1.20-22.46), urinary tract infection rate (OR 3.91, CI 1.13-21.0), voided volume (OR 4.53, CI 1.85-11.99), increased standardized voiding frequency (OR 7.40, CI 2.15-39.66), and urodynamic findings indicative of neurogenic lower urinary tract dysfunction. Expanded Disability Status Scale shows no correlation. Those parameters (except post-void residual) are also associated with reduced bladder compliance, as potential risk for kidney damage. CONCLUSION: Therefore, bladder diary and urinary tract infection rate should be routinely assessed to identify patients who require urodynamics.

Electrochemically activated solution as bladder irrigation-An individual curative trial in patients with neurogenic lower urinary tract dysfunction and recurrent urinary infections.

AIMS: Driven by increasing awareness of antibiotic stewardship, especially in the vulnerable group of patients with neurogenic lower urinary tract dysfunction (NLUTD), whose frequent need for invasive interventions leads to a high incidence of recurrent urinary tract infections (rUTIs), the goal was to find an alternative to antibiotic treatment. Our intention was for the treatment to be locally administered and well-tolerated as well as to avoid the risk of antimicrobial resistance. METHODS: A retrospective analysis of 12 catheterized NLUTD patients was performed within the setting of an individual curative trial. The decision to implement the investigational intervention was made on an individual basis with the aim of eliminating lower urinary tract bacteria before diagnostic procedures or to treat rUTI. Electrochemically activated solution (ECAS) was used as bladder irrigation (BI). The following assessments were undertaken: microbiological analysis of urine, analysis of leukocytes/erythrocytes (per µl urine); microbial resistance and sensitivity to antibiotics before and after therapy; clinical signs and patients' state of health. RESULTS: Eradication of bacteria or an increase in microbial sensitivity to antibiotics was observed in 50%-70% of patients. No adverse events were seen. Due to the restrictions of an individual curative trial, the results are limited by the small number of patients and the absence of a control group. CONCLUSION: In NLUTD patients with rUTIs, the use of ECAS BI to eliminate bacteriuria before invasive procedures (e.g., urodynamics, preoperative procedures) or to treat rUTI was shown to be a promising alternative to antibiotic treatment.

Overactive bladder syndrome - focus onto detrusor overactivity.

INTRODUCTION AND HYPOTHESIS: To determine in patients with overactive bladder (OAB), urodynamic differences as well to compare the characteristics of patient's, with presence of detrusor overactivity on urodynamics with those with absence of detrusor overactivity. METHODS: Taking into account the urodynamic findings, the patients with OAB symptoms were categorized into one of two groups: group 1 (with detrusor overactivity) or group 2 (without detrusor overactivity), and comparative analyses for both groups were performed (epidemiological data, patient history, urodynamic criteria, bladder diaries, IC-OAB, IC-OABqol - questionnaires). RESULTS: There was a significant difference in age as well in the disease duration between group 1 and group 2. Although the mean number of micturitions and nocturia episodes was comparable, the numbers of urgency episodes differed significantly. The number of 'wet' patients was significantly higher in the group 1 with the significantly higher number of incontinence episodes. Group 1 demonstrated higher OAB symptom scores and higher impact on the patients' quality of life. CONCLUSIONS: More than half of the patients complaining of urgency-frequency do not have detrusor overactivity upon urodynamic testing, and only half have detrusor overactivity that correlates with urge perception. The patients with no detrusor overactivity appear to be significantly younger and have fewer symptoms, with a less pronounced impact on quality of life. They also have significantly higher maximal bladder capacity. This data supports the hypothesis that both conditions are different phases (early and late) of the same pathological state, or may be two different subtypes of OAB.

Good urodynamic practices in a non-specialized center: quality control analysis.

OBJECTIVES: To review the quality of urodynamic studies performed in one Center in order to assess adherence to the ICS Good Urodynamic Practice Guidelines. METHODS: Sixty-two consecutive urodynamic studies performed between March 2012 and May 2013 were retrospectively reviewed. We followed a list of common features to analyze all records. RESULTS: 10.17% of the studies showed a significant drop in Pabd not mentioned in the study report. We found straining in 15.25% of the traces that was recognized and informed in the reports. We did not find many equipment artifacts, only pump vibrations. Uroflowmetry performed previously to the test is very important to compare its results with the ones obtained at the pressure- flow study. 50.8% of the studies had a non-valuable uroflowmetry. CONCLUSIONS: The high rate of non-valuable uroflowmetries was in most of the cases due to an insufficient voiding volume. We think we meet very good standards although this is not a reference unit; nevertheless we still need to improve in many aspects.

Las buenas prácticas en urodinámica como un indicador de calidad en un Servicio no especializado / Good urodynamic practices in a non-specialized center: quality control analysis

OBJETIVO: Evaluación de estudios urodinámicos realizados en un Centro no especializado para valorar su calidad en relación con las Guías de Buenas Prácticas en Urodinámica de la Sociedad Internacional de Incontinencia. MÉTODOS: Se analizaron 62 estudios urodinámicos realizados entre marzo 2012 y mayo 2013 de forma retrospectiva. Se empleó para ello una serie de parámetros característicos comunes en todos los trazados. Se realizó una uroflujometría previa para su comparación posterior con la del estudio presión-flujo. RESULTADO: El 10,17% de los trazados mostró un descenso significativo de la Pabd no informado en el estudio. En el 15,25% se constató "presión al orinar", la cual fue reconocida e informada en las conclusiones. No hemos encontrado mayores artefactos, salvo vibraciones por la bomba. Como hallazgo más relevante, el 50,8% de los estudios presentaba una uroflujometría previa no vaporable. CONCLUSIONES: La elevada tasa de uroflujometrías no valorables fue en la mayoría de los casos por un volumen miccional insuficiente. Creemos que alcanzamos una elevada performance en la realización de nuestros estudios, a pesar de no tratarse de un centro especializado. El análisis retrospectivo nos permite detectar nuestros errores para poder tomar las medidas de corrección pertinentes

OBJECTIVES: To review the quality of urodynamic studies performed in one Center in order to assess adherence to the ICS Good Urodynamic Practice Guidelines. METHODS: Sixty-two consecutive urodynamic studies performed between March 2012 and May 2013 were retrospectively reviewed. We followed a list of common features to analyze all records. RESULTS: 10.17% of the studies showed a significant drop in Pabd not mentioned in the study report. We found straining in 15.25% of the traces that was recognized and informed in the reports. We did not find many equipment artifacts, only pump vibrations. Uroflowmetry performed previously to the test is very important to compare its results with the ones obtained at the pressure-flow study. 50.8% of the studies had a non-valuable uroflowmetry. CONCLUSIONS: The high rate of non-valuable uroflowmetries was in most of the cases due to an insufficient voiding volume. We think we meet very good standards although this is not a reference unit; nevertheless we still need to improve in many aspects

Asymptomatic renocolic fistula as a complication of staghorn calculus: case report.

OBJECTIVE: To report a complication of a staghorn stone in a non-functioning right kidney. METHODS: We present a 47 year old female with right lumbar pain and history of recurrent urinary tract infection (UTI). After an acute pyelonephritis episode, a right staghorn stone was diagnosed in a non-functioning right kidney. RESULTS: During right nephrectomy, we found a renocolic fistula not observed in the imaging studies before surgery. We performed a simple closure of the colon wall after resection of the fistula. CONCLUSION: Asymptomatic renocolic fistula is a rare complication of an acute pyelonephritis secondary to a staghorn stone.

Fístula reno-cólica asintomática como complicación renal coraliforme / Asymptomatic renocolic fistula as a complication of staghorn calculus: Case report

OBJETIVO: Presentamos complicación de una litiasis coraliforme en riñón no funcionante. MÉTODOS: Paciente femenina de 47 años con dolor lumbar derecho e infecciones urinarias a repetición. Luego de una pielonefritis aguda, se diagnostica una litiasis coraliforme en un riñón no funcionante. RESULTADO: Durante la nefrectomía derecha se comprueba una fistula reno-colónica no informada en los estudios de imágenes previos a la cirugía. Luego de la resección de la misma, se realiza un cierre simple de la pared colónica involucrada. CONCLUSIONES: La fistula reno-colónica es una complicación poco frecuente de una pielonefritis aguda secundaria a litiasis coraliforme (AU)

OBJECTIVE: To report a complication of a staghorn stone in a non-functioning right kidney. METHODS: We present a 47 year old female with right lumbar pain and history of recurrent urinary tract infection (UTI). After an acute pyelonephritis episode, a right staghorn stone was diagnosed in a non-functioning right kidney. RESULTS: During right nephrectomy, we found a renocolic fistula not observed in the imaging studies before surgery. We performed a simple closure of the colon wall after resection of the fistula. CONCLUSION: Asymptomatic renocolic fistula is a rare complication of an acute pyelonephritis secondary to a staghorn stone (AU)

Tumor testicular del síndrome adrenogenital. A propósito de un caso y diagnóstico intraoperatorio / Testicular tumour of the adrenogenital syndrome. A case report and frozen section diagnosis

Presentamos el caso de un varón de 34 años con hiperplasia adrenal congénita por déficit de 21-hidroxilasa diagnosticada durante la infancia. En la actualidad presenta múltiples masas testiculares hipoecogénicas y bilaterales. Se optó por realizar biopsia intraoperatoria de una de estas lesiones, observándose un aspecto microscópico constituido por cordones y trabéculas de grandes células poligonales con abundante citoplasma y núcleo redondo con patrón cromatínico fino, similares a las células de Leydig, entre los cuales serpenteaban tractos fibrosos más o menos gruesos, los cuales nos ayudaron a emitir el diagnóstico de tumor testicular del síndrome adrenogenital. En los pacientes con síndrome adrenogenital es típica la aparición de tumoraciones testiculares bilaterales originadas como consecuencia de niveles elevados de ACTH en sangre periférica. Las teorías actuales orientan a un origen a partir de células madre totipotenciales del estroma testicular. Son tumores de gran parecido morfológico, radiológico y bioquímico con los tumores de células de Leydig, por lo que es de gran importancia realizar un diagnóstico diferencial acertado y evitar así cirugías radicales realizadas clásicamente con estas lesiones(AU)

We present a case of a 34 years old male with congenital adrenal hyperplasia caused by 21-hidroxilase deficiency, diagnosed during his childhood. Currently he presents multiple testicular hypoechogenic and bilateral masses. We chose to perform intraoperatory biopsy in one of these lesions, observing a microscopic appearance constituted by cords and trabeculae of large polygonal cells with abundant cytoplasm and round nuclei with fine chromatin pattern similar to Leydig cells, including meandering fibrous tracts of more or less thickness, which helped us delivering the diagnosis of testicular tumor of adrenogenital syndrome. In patients with adrenogenital syndrome is typical the arising of bilateral testicular tumors as a result of elevated levels of adrenocorticotropin hormone (ACTH) in peripheral blood. Current theories directed to an origin from pluripotential stem cells from testicular stroma. These tumors are morphologically, biochemically and radiologically very similar to Leydig cell tumours, so it is very important to make a correct differential diagnosis and avoid radical surgery performed classically with these lesions(AU)

[The treatment of female stress urinary incontinence (SUI) using fascia lata in a rural hospital]. / Tratamiento de la incontinencia de orina de esfuerzo (IUE) femenina mediante el empleo de fascia lata en un hospital rural.

OBJECTIVES: Pubovaginal sling has been the treatment of choice for female SUI over the last two years. Those made with autologous materials have demonstrated a lower rate of complications. We present our experience using autologous fascia lata. METHODS: Between May 2005 and July 2006 we performed 10 procedures through a suprapubic approach. In eight cases they were ascended to the retropubic space using needles, and in 2 cases we employed the vaginal tunneler (Tyco). In the 8 initial cases both sling branches were anchored to the Cooper's ligament. In the remainder two cases they were anchored to the fascia of the obliquus externus muscle. RESULTS: Mean age was 57.7 years; mean follow-up time was 14.8 months (6-20). In 6 cases cystocele was simultaneously corrected. Hospital stay was 72 hours. In two cases, section of the autologous sling was required due to excessive correction. Four patients keep using pads; nevertheless, all 10 patients refer no SUI. Post-operative urine culture was positive in four patients, with negative controls. One case presented vaginal candidiasis. CONCLUSIONS: Autologous fascia lata pubovaginal sling is an effective low cost treatment, with a low complication rate.

Tratamiento de la incontinencia de orina de esfuerzo (IUE) femenina mediante elempleo de la fascia lata en un hospital rural / The treatment of female stress urinary incontinence (SUI) using fascia lata in a rural hospital

Objetivo: El sling pubovaginal ha sido en los últimos años el tratamiento de elección para la IUE femenina. Los de material autólogo han demostrado el menor índice de complicaciones. Presentamos nuestra experiencia empleando fascia lata autóloga. Método: Entre mayo de 2005 y julio de 2006 realizamos 10 tratamientos por vía suprapúbica. En 8 casos se ascendieron al espacio retropubiano mediante agujas y en 2 casos se empleó un tunelizador vaginal (Tyco®). En los 8 iniciales se fijaron ambas ramas del sling al ligamento de Cooper. En los 2 restantes se fijaron a la fascia del oblicuo mayor. Resultados: El promedio de edad fue de 57,7 años; el tiempo de seguimiento promedio fue de 14,8 meses (6-20). En 6 casos se corrigió simultáneamente un cistocele. La internación fue de 72 hs. En 2 casos se requirió la sección del sling autólogo debido a hipercorrección. Cuatro pacientes continúan empleando toallas higiénicas, sin embargo las 10 pacientes no refieren IUE. En 4 pacientes el urocultivo posoperatorio fue positivo, con controles negativos. Un caso presentó una candidiasis vaginal. Conclusión: El sling pubovaginal con fascia lata autóloga es un tratamiento efectivo de bajo costo, con una baja tasa de complicaciones (AU)

Objectives: Pubovaginal sling has been the treatment of choice for female SUI over the last two years. Those made with autologous materials have demonstrated a lower rate of complications. We present our experience using autologous fascia lata. Methods: Between May 2005 and July 2006 we performed 10 procedures through a suprapubic approach. In eight cases they were ascended to the retropubic space using needles, and in 2 cases we employed the vaginal tunneler (Tyco®). In the 8 initial cases both sling branches were anchored to the Cooper's ligament. In the remainder two cases they were anchored to the fascia of the obliquus externus muscle. Results: Mean age was 57.7 years; mean follow-up time was 14.8 months (6-20). In 6 cases cystocele was simultaneously corrected. Hospital stay was 72 hours. In two cases, section of the autologous sling was required due to excessive correction. Four patients keep using pads; nevertheless, all 10 patients refer no SUI. Post-operative urine culture was positive in four patients, with negative controls. One case presented vaginal candidiasis. Conclusions: Autologous fascia lata pubovaginal sling is an effective low cost treatment, with a low complication rate (AU)

[Importance of the neurophysiological evoked potential register during the implantation of a sacral neuromodulator]. / Importancia del registro neurofisiológico evocado durante la colocación de un neuromodulador sacro.

OBJECTIVES: Sacral neuromodulation is a new treatment option in patients with urge incontinence, urgency-frequency and urinary retention refractory to the pharmacological therapy. The electrophysiological monitoring provides direct and immediate feedback about the function of nerves. We evaluated the utility of the electrophysiological monitoring to assert the correct position of the lead at the third sacral root (S3). METHOD: We registered the sacral-vesicourethral and sacral plantar evoked potentials in two patients (a 55 years old man and a 37-year-old woman) during the implant of a sacral neuromodulator (Interstim, Medtronic, MN USA). RESULTS: We registered vesico-urethral and sacroplantar potentials in response to sacral stimulation. We found vesical evoked potentials after the stimulation of S3 and S4 and plantar responses after the stimulation of S2 and S3. The vesico-urethral evoked potentials had a latency of 25.10 mseg in our first case and 28.52 mseg in the second. The sacroplantar evoked potentials had a latency of 20.80 mseg and 22.46 mseg respectively. We observed the evoked potential register during the surgery prior to the visual motor and sensory responses with a lower intensity of stimulation (average 3.5 mAmp). The only sacral root in which we could find both responses was in S3. CONCLUSION: The electrophysiological monitoring was helpful in identifying the right position of the lead at the correct sacral root. It avoided the necessity of high stimulation intensity during the procedure.

Importancia del registro neurofisiológico evocado durante la colocación de un neuromodulador sacro / Importance of the neurophysiological evoked potential register during the implantation of a sacral neuromodulator

OBJETIVOS: Para la correcta ubicación del electrodo en sacro 3 (S3) durante la cirugía de implante de un neuromodulador, empleamos en la etapa de estimulación transitoria el registro de potenciales evocados con captación a nivel vesicouretral y en la planta del pie (flexor corto del hallux). METODOS: Realizamos esta experiencia en 2 pacientes. Colocamos un electrodo anular montado sobre una sonda Foley 10F en el cuello vesical y una aguja coaxial en flexor corto del hallux de cada bóveda plantar. Al estimular la región sacra registramos los potenciales evocados sacro-vesicouretrales y sacro-plantares. RESULTADOS: Al estimular la raíz S3 registramos un potencial evocado vesicouretral de 25.10 mseg en el primer paciente y de 28.52 mseg en el segundo y un potencial evocado sacro-plantar de 20.80 mseg y 22.46 mseg respectivamente. Dichos potenciales no se observan simultáneamente al estimular otras raíces sacras. El registro de estos potenciales antecede a la observación clínica de respuestas de contracción del esfínter anal y del flexor del primer dedo del pie. Cabe destacar que la respuesta evocada a nivel de la unión uretrovesical es conducida a través de fibras del sistema nervioso vegetativo y la respuesta evocada con captación a nivel de la planta del pie viaja a través del sistema somático. CONCLUSIONES: El registro de los potenciales evocados sacro-vesicouretrales y sacro-plantares durante la colocación de un neuromodulador sacro es una herramienta útil para asegurar la localización en S3 del electrodo sacro (AU)

OBJECTIVES: Sacral neuromodulation is a new treatment option in patients with urge incontinence, urgency-frequency and urinary retention refractory to the pharmacological therapy. The electrophysiological monitoring provides direct and immediate feedback about the function of nerves. We evaluated the utility of the electrophysiological monitoring to assert the correct position of the lead at the third sacral root (S3). METHOD: We registered the sacral-vesicourethral and sacral plantar evoked potentials in two patients (a 55 years old man and a 37-year-old woman) during the implant of a sacral neuromodulator (Interstim, Medtronic, MN USA). RESULTS: We registered vesico-urethral and sacroplantar potentials in response to sacral stimulation. We found vesical evoked potentials after the stimulation of S3 and S4 and plantar responses after the stimulation of S2 and S3. The vesico-urethral evoked potentials had a latency of 25.10 mseg in our first case and 28.52 mseg in the second. The sacroplantar evoked potentials had a latency of 20.80 mseg and 22.46 mseg respectively. We observed the evoked potential register during the surgery prior to the visual motor and sensory responses with a lower intensity of stimulation (average 3.5 mAmp). The only sacral root in which we could find both responses was in S3. CONCLUSION: The electrophysiological monitoring was helpful in identifying the right position of the lead at the correct sacral root. It avoided the necessity of high stimulation intensity during the procedure

Tratamiento farmacológico de la disfunción eréctil / Farmacologic treatment of the erectile disfunction

Anatomía funcional del pene.- Mecanismos que regulan la erección.- Disfunción sexual eréctil: Etiología, diagnóstico, tratamiento.- Medicación oral; Aplicación transepitelial de drogas vasoactivas; Tratamiento hormonal; Fármacotest; Inyección intracavernosa: complicaciones.- Disfunción sexual eréctil orgánica y psicógena con erección farmacológica.- Disfunción sexual eréctil en la diabetes y el tabaquismo

Tratamiento farmacológico de la disfunción eréctil / Farmacologic treatment of the erectile disfunction

Anatomía funcional del pene.- Mecanismos que regulan la erección.- Disfunción sexual eréctil: Etiología, diagnóstico, tratamiento.- Medicación oral; Aplicación transepitelial de drogas vasoactivas; Tratamiento hormonal; Fármacotest; Inyección intracavernosa: complicaciones.- Disfunción sexual eréctil orgánica y psicógena con erección farmacológica.- Disfunción sexual eréctil en la diabetes y el tabaquismo