The effect of pelvic floor muscle training alone or in combination with electrostimulation in the treatment of sexual dysfunction in women with multiple sclerosis.

BACKGROUND: Sexual dysfunction (SD) affects up to 80% of multiple sclerosis (MS) patients and pelvic floor muscles (PFMs) play an important role in the sexual function of these patients. OBJECTIVES: The objective of this paper is to evaluate the impact of a rehabilitation program to treat lower urinary tract symptoms on SD of women with MS. METHODS: Thirty MS women were randomly allocated to one of three groups: pelvic floor muscle training (PFMT) with electromyographic (EMG) biofeedback and sham neuromuscular electrostimulation (NMES) (Group I), PFMT with EMG biofeedback and intravaginal NMES (Group II), and PFMT with EMG biofeedback and transcutaneous tibial nerve stimulation (TTNS) (Group III). Assessments, before and after the treatment, included: PFM function, PFM tone, flexibility of the vaginal opening and ability to relax the PFMs, and the Female Sexual Function Index (FSFI) questionnaire. RESULTS: After treatment, all groups showed improvements in all domains of the PERFECT scheme. PFM tone and flexibility of the vaginal opening was lower after the intervention only for Group II. All groups improved in arousal, lubrication, satisfaction and total score domains of the FSFI questionnaire. CONCLUSION: This study indicates that PFMT alone or in combination with intravaginal NMES or TTNS contributes to the improvement of SD.

Rizotomía sacra percutánea por radiofrecuencia en el tratamiento de la hiperactividad del detrusor neurogénico en pacientes con lesiones de la médula espinal / Percutaneous radiofrequency sacral rhizotomy in the treatment of neurogenic detrusor overactivity in spinal cord injured patients

Objetivo: Evaluar los efectos de la rizotomía sacral percutánea por radiofrecuencia en pacientes con lesión de la médula espinal sobre parámetros urodinámicos (capacidad cistométrica máxima [CCM] y presión del detrusor a capacidad cistométrica máxima [PdetCCM]). Material y Métodos: En este estudio prospectivo se evaluó a 8 pacientes con LME (4 hombres y 4 mujeres) con una media de edad de 31,3 años (de 22 a 41). El intervalo medio entre la lesión de la médula espinal y la rizotomía fue de 53,5 meses (entre 20 y 96). A todos los pacientes se les practicó un bloqueo anestésico bajo control fluoroscópico de la tercera raíz sacral de forma bilateral con bupivacaína 0,5%. Se eligió para rizotomía sacral percutánea por radiofrecuencia a los que respondieron con un aumento en la capacidad vesical. Se procedió a la evaluación urodinámica de todos los pacientes a los 6 y los 12 meses tras la realización del procedimiento. Se consignaron tanto la CCM como la PdetCCM. Resultados: Todos los pacientes mostraron una mejora significativa en la CCM a los 12 meses. El volumen vesical medio aumentó de los 100,2±57,1 a 282,9±133,4 ml (p < 0,05). La PdetCCM se redujo de 82,4±31,7 a 69,9±28,7 cm H2O (p = 0,2). Tres pacientes con disreflexia autonómica experimentaron un alivio total de los síntomas tras el procedimiento. A los 12 meses se observó una reaparición de la hiperactividad del detrusor en todos los pacientes. Un paciente presentó abolición de las erecciones reflejas tras el procedimiento. No se observaron complicaciones de importancia en relación con la rizotomía. Conclusiones: La rizotomía sacral percutánea por radiofrecuencia es una técnica mínimamente invasiva, de baja morbilidad, que puede aumentar la CCM. Existe una tendencia hacia la reducción de la PdetCCM en pacientes con LME a los 12 meses, a pesar de que no se alcanza un nivel estadísticamente significativo (AU)

Introduction: To evaluate the effects of percutaneous radiofrequency sacral rhizotomy in spinal cord injured (SCI) patients on urodynamic parameters (maximum cystometric capacity — MCC and detrusor pressure at maximum cystometric capacity - PdetMCC). Material and Methods: This prospective study assessed eight patients with SCI (four men and four women) with a mean age of 31.3 years (22 to 41). Mean interval period between spinal cord lesion and rhizotomy was 53.5 months (20 to 96). All patients underwent an anesthetic block of the 3rd sacral root bilaterally using 0.5% bupivacaine under fluoroscopic control. Those who responded with an increase on bladder capacity were selected to undergo the percutaneous radiofrequency sacral rhizotomy. All patients underwent urodynamic evaluation at 6 and 12months following the procedure. MCC and PdetMCC were recorded. Results: All patients presented a significant improvement on MCC after 12 months. The mean vesical volume increased from 100.2±57.1 to 282.9±133.4 ml (p<0.05). The PdetMCC reduced from 82.4±31.7 to 69.9±28.7 cmH2O (p = 0.2). Three patients with autonomic dysreflexia had complete relief of symptoms after the procedure. At 12 months, recurrence of detrusor hyperactivity was observed in all patients. One patient presented abolishment of reflex erections after the procedure. No major complications related to the rhizotomy were noted.C onclusions: Percutaneous radiofrequency sacral rhizotomy is a minimally invasive technique with low morbidity able to increase MCC. There is a trend towards the reduction of the PdetMCC in SCI patients at 12 months, although statistical significance was not reached (AU)

[Percutaneous radiofrequency sacral rhizotomy in the treatment of neurogenic detrusor overactivity in spinal cord injured patients]. / Rizotomía sacra percutánea por radiofrecuencia en el tratamiento de la hiperactividad del detrusor neurogénico en pacientes con lesiones de la médula espinal.

INTRODUCTION: To evaluate the effects of percutaneous radiofrequency sacral rhizotomy in spinal cord injured (SCI) patients on urodynamic parameters (maximum cystometric capacity - MCC and detrusor pressure at maximum cystometric capacity - PdetMCC). MATERIAL AND METHODS: This prospective study assessed eight patients with SCI (four men and four women) with a mean age of 31.3years (22 to 41). Mean interval period between spinal cord lesion and rhizotomy was 53.5 months (20 to 96). All patients underwent an anesthetic block of the 3rd sacral root bilaterally using 0.5% bupivacaine under fluoroscopic control. Those who responded with an increase on bladder capacity were selected to undergo the percutaneous radiofrequency sacral rhizotomy. All patients underwent urodynamic evaluation at 6 and 12 months following the procedure. MCC and P(det)MCC were recorded. RESULTS: All patients presented a significant improvement on MCC after 12 months. The mean vesical volume increased from 100.2±57.1 to 282.9±133.4ml (p<0.05). The P(det)MCC reduced from 82.4±31.7 to 69.9±28.7cmH(2)O (p=0.2). Three patients with autonomic dysreflexia had complete relief of symptoms after the procedure. At 12 months, recurrence of detrusor hyperactivity was observed in all patients. One patient presented abolishment of reflex erections after the procedure. No major complications related to the rhizotomy were noted. CONCLUSIONS: Percutaneous radiofrequency sacral rhizotomy is a minimally invasive technique with low morbidity able to increase MCC. There is a trend towards the reduction of the P(det)MCC in SCI patients at 12 months, although statistical significance was not reached.

Myocardial bridging: cases reports.

We report 2 cases of Myocardial Bridge (MB). MB, even though a very frequent anomaly (found out in 85% of autopsies), often is asymptomatic. It is hard to diagnose in patients affected by coronary artery disease, seldomly found out on selective coronary angiograms (in 16-20% of chest pain cases). MB can be considered as one of the causes of coronary artery disease.

[Dilemma in the treatment of angiomyolipoma]. / Dilema en el tratamiento del angiomiolipoma.

OBJECTIVE: To present our experience with renal angiomyolipoma. METHODS: The series comprised 27 patients (26 female, 1 male) with renal angiomyolipoma. Twenty-three (85%) had unilateral renal involvement and of the 4 remaining patients (15%) with bilateral involvement, three (10%) had tuberous sclerosis. RESULTS: Due to the complications, three patients with bilateral and one patient with unilateral renal involvement required surgery. Mean patient follow-up was 38 months. CONCLUSIONS: Surgery is warranted in patients with tumors of more than 4 cm, symptomatic or associated with tuberous sclerosis. Regular control evaluation is indicated for tumors less than 4 cm.

Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting.

OBJECTIVES: To examine the variability of bladder outlet obstruction and mild lower urinary tract symptoms in patients with benign prostatic hyperplasia (BPH) followed up by watchful waiting. METHODS: The International Prostate Symptom Score (IPSS) has four questions related to voiding symptoms and three related to filling symptoms. Scores of 0 to 7, 8 to 19, and 20 to 35 represent mild, moderate, and severe symptoms, respectively. Over a period of 36 months the IPSS questionnaire was administered to 479 patients 50 to 81 years old (mean age 63) with BPH. A pressure-flow study was used to determine the presence of bladder outlet obstruction. On the basis of their scores, the patients were classified into 50 with mild, 227 with moderate, and 202 with severe symptoms. In the present study only patients with a mild score were analyzed. RESULTS: Of 50 patients with mild symptoms, 16 (32%) had bladder outlet obstruction. After a period of 9 to 22 months (mean 17) of watchful waiting, these 16 patients were reviewed. Twelve (75%) of the 16 had bladder outlet obstruction reconfirmed by pressure-flow studies, and 3 (18.8%) of 16 had increased symptoms (moderate symptomatic) and underwent treatment (1 began pharmacologic treatment, and 2 chose transurethral resection). A total of 4 (25%) of 16 patients still had mild voiding disturbances and refused the second urodynamic evaluation. The remaining 34 patients with no obstruction had annual routine follow-up and had persistent mild symptom scores and normal uroflowmetric results. These patients did not undergo another pressure-flow evaluation. CONCLUSIONS: A pressure-flow study is routinely avoided in patients with a mild IPSS. From symptoms alone it was not possible to diagnose bladder outlet obstruction in these patients. Pressure-flow studies and symptom profiles measure different aspects of the clinical condition. After a mean follow-up of 17 months of watchful waiting, 13 (81.2%) of 1 6 patients were clinically stable. Because the need for therapy is dictated by quality of life, it is difficult to propose treatment for patients with minimal symptoms, even in the presence of bladder outlet obstruction.

Quality of life after partial penectomy for penile carcinoma.

OBJECTIVES: To investigate the impact of partial penectomy on the quality of life of patients with carcinoma of the penis. METHODS: Fourteen patients who had undergone partial penectomy for penile cancer were studied. Their median age was 50.5 years and the median time of follow-up was 11.5 months. The quality of life was evaluated in three dimensions: social adjustment, sexuality, and emotional state. The patients underwent a semistructured interview and were asked to complete the Overall Sexual Functioning Questionnaire, the Social Problem Questionnaire, the General Health Questionnaire, and the Hospital Anxiety and Depression Scale. RESULTS: In 9 (64%) patients, the overall sexual function was normal or slightly decreased. Only 2 (14%) men had precarious or absent sexual function. The masculine self-image and the relationship with their partners remained practically unchanged in all the patients. Sexual interest and satisfaction remained normal or slightly reduced in 9 and 12 patients, respectively. The frequency of sexual intercourse was unchanged or slightly decreased in 9 patients. Three patients had no sexual intercourse after surgery. No significant levels of anxiety and depression were found. Within the areas of living conditions, family life, and interactions with other people, all the patients remained as they were before the surgery. CONCLUSIONS: Patients who undergo partial penectomy for penile cancer can maintain the quality of life (in social, psychological, and sexual terms) at levels similar to those that existed in the period before surgery.

Dilema en el tratamiento del angiomiolipoma / Dilema in angiomiolipoma treatment

En el período de marzo de 1985 a mayo de 1996, fueron tratados 26 pacientes del sexo femenino y uno del sexo masculino con diagnóstico de angiomiolipoma renal. Veintitres pacientes presentaban compromiso renal unilateral (85 por ciento) y, de las 4 pacientes con compromiso bilateral (15 por ciento), tres tenían asociación con esclerosis tuberculosa (10 por ciento). Debido a complicaciones, tres tenían asociación con esclerosis tuberculosa (10 por ciento). Debido a complicaciones, tres pacientes con compromiso bilateral y uno con unilateral necesitaron tratamiento quirúrgico. Los pacientes están en seguimiento, por un período mediano de 38 meses

Antegrade endopyelotomy for pelvi-ureteric junction obstruction in children.

OBJECTIVE: To compare the results of repairing pelvi-ureteric junction (PUJ) obstruction by percutaneous endopyelotomy in children with a similar series carried out in adults. PATIENTS AND METHODS: Nine children with primary (six) or secondary (three) PUJ obstruction were treated using a one-stage cold-knife percutaneous endopyelotomy. The success and morbidity rates were compared with a series of 61 adults with primary (46) or secondary (15) PUJ obstruction treated similarly. RESULTS: In children, endopyelotomy was successful in five of six with primary and two of three with secondary PUJ obstruction, with a mean follow-up of 30 months (range 18-56). In the adults, endopyelotomy was successful in 38 of 46 (83%) with primary and 12 of 15 with secondary PUJ obstruction, an overall success rate of 82%, with a mean follow-up of 42 months (range 9-86). There was no statistical difference in the success rates with primary and secondary endopyelotomy between adults and children (P = 0.58). Failures were associated with high-grade hydronephrosis, a stenotic segment > 1.5 cm long and technical problems. Morbidity occurred in one of nine children and 3.2% of the adults. CONCLUSION: This early experience suggests that percutaneous endopyelotomy can be performed safely and successfully in children with primary PUJ obstruction. However, in secondary stenosis, the results were less than optimal. Larger series should be analysed to form definitive conclusions on the role of endopyelotomy for the treatment of PUJ obstruction in children, given the high rate of success of open pyeloplasty and its minimal morbidity.

Correlation between the International Prostatic Symptom Score and a pressure-flow study in the evaluation of symptomatic benign prostatic hyperplasia.

PURPOSE: We examined the relationship between the International Prostatic Symptom Score (I-PSS) and the occurrence of bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: The American Urological Association developed a questionnaire to quantify the severity of symptoms resulting from BPH. A further question relating the impact of BPH to the quality of life was subsequently added. This questionnaire has been adopted by the World Health Organization and is known as the I-PSS. There are 4 questions related to obstructive symptoms and 3 related to irritative symptoms. Scores of 0 to 7, 8 to 19 and 20 to 35 represent mild, moderate and severe symptoms, respectively. During an 18-month interval the I-PSS questionnaire was administered to 258 patients 50 to 81 years old (mean age 63 years) with BPH. A pressure-flow study was used to determine the presence of bladder outlet obstruction in 227 patients. Based on the scores, the patients were divided into 31 with mild, 116 with moderate and 111 with severe obstruction. The pressure-flow study was not conducted on patients with a mild symptom score. RESULTS: Of the patients with a severe symptom score 92 (82.9%) had bladder outlet obstruction, compared to 62 (53.4%) with a moderate symptom score. Statistical analysis (Pearson chi-square test) showed that there was a significant positive correlation between the symptoms and the presence of bladder outlet obstruction. Thus, when the I-PSS was greater than 28, the probability of bladder outlet obstruction was more than 0.91. Stratification of the results according to the obstructive (0 to 20) and irritative (0 to 15) symptoms of the I-PSS yielded a significant positive correlation between obstructive symptoms and the presence of bladder outlet obstruction. Thus, when the obstructive symptom score was greater than 15, the probability of bladder outlet obstruction was greater than 0.91. CONCLUSIONS: When the total I-PSS is greater than 28 or the obstructive symptom score is greater than 15, a pressure-flow study must be avoided.

Percutaneous treatment of bladder stones.

A total of 36 patients with bladder stones underwent percutaneous suprapubic cystolithotripsy. The successful rate was 89%. There were 11% failures due to nonfragmentation of the stones by the ultrasound probe. According to the presence of associated diseases 3 groups of patients were established. Two groups underwent concomitant treatments for benign prostatic hyperplasia and urethral stricture. No complications occurred even in patients with concomitant treatment. There was no statistically significant difference when these groups were compared (p > 0.05). Fluoroscopy was not necessary during the procedure. Since the technique is simple, safe and effective, it represents an alternative in the management of bladder stones.

Immunoprophylaxis of superficial bladder cancer: a prospective and randomized comparison of oral versus intravesical Bacillus Calmette-Guerin.

A total of 84 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to three treatment groups: I. Control group-transurethral resection (TUR-BT) discontinued within the study. II. Oral BCG group-TUR-BT plus BCG (Moreau). III. Intravesical BCG group-TUR-BT plus BCG. Of 9 patients in the control group, 8 (89%) experienced tumor recurrence during a mean follow-up of 20 months. Of the 33 patients in the oral BCG group, 13 patients (39.3%) had recurrence during a mean follow-up of 39 months. Of the 42 patients in the intravesical group, 8 patients (19%) had recurrence in a 30-month mean follow-up. The incidence of complications was higher in the intravesical (33.4%) than in the oral BCG group (24.2%). These results showed that intravesical BCG is a more effective immunotherapy; however, oral BCG can be utilized in patients who do not accept intravesical BCG administration.

Experimental studies on BCG in hamsters.

The effects of BCG in the treatment of superficial bladder cancer in man are known, but the mechanism is not quite well understood. Thirty-six hamsters received BCG through three routes: intravesical, intradermal and oral. Each group was composed of 12 animals; BCG was administered to 9 and only saline solution to 3 hamsters. BCG was given once a week for six weeks. The animals were sacrificed at 20, 30 and 65 days after the last administration of BCG. The anatomopathologic study revealed granulomatous reaction in the liver of 5 hamsters and in the spleen of 4 other animals of the intravesical group. In all groups that received BCG, hyperplasia of periarteriolar lymphoid tissue (T zone) of the spleen was observed. We support the view that BCG promotes a systemic reaction whatever the route of administration may be.

Oral or intravesical bacillus Calmette-Guerin immunoprophylaxis in bladder carcinoma.

A total of 71 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to 3 treatment groups: control group--transurethral resection discontinued within the study, oral bacillus Calmette-Guerin (BCG) group--transurethral resection of bladder tumor plus BCG (Moreau) and intravesical BCG group--transurethral resection of bladder tumor plus BCG. Of 9 patients in the control group 8 (89%) experienced tumor recurrence during a mean followup of 20 months. Of the 28 patients in the oral BCG group 11 (39.3%) had recurrence during a mean followup of 36 months. Of the 34 patients in the intravesical group 6 (18%) had recurrence in a 24-month mean followup. The incidence of complications was higher in the intravesical (41.2%) than in the oral BCG group (28.5%). These results show that intravesical BCG is a more effective immunotherapy; however, oral BCG can be used in patients who do not accept intravesical BCG administration.

Percutaneous nephrectomy in nonfunctioning kidneys: a preliminary report.

Nephrectomy is indicated for the removal of highly damaged kidneys. Several times patients are asymptomatic, and although the operation has a low morbidity rate they will refuse it. The development of new endourological techniques of percutaneous access to the kidney in experimental studies on liquefaction and aspiration of tissues, and the idea taken from the old resectoscope models using nonelectrical aids served to inspire our technique of percutaneous nephrectomy. Our patient presented with a nonfunctioning kidney due to ureteral obstruction and ultrasound demonstrated a severe decrease in renal parenchyma. Percutaneous access to the kidney was performed through the conventional manner and the remaining parenchyma was removed with biopsy and Lowsley forceps. Bleeding was minimum and a 22F nephrostomy Foley catheter was kept in place for 72 hours. As far as new instruments are developed, percutaneous nephrectomy represents a surgical option to remove nonfunctioning kidneys in highly selected patients.

Internal urethrotomy of the prostatic urethra or transurethral resection in benign prostatic hyperplasia.

Transurethral resection of the prostate is the most common technique for the treatment of benign prostatic enlargement. The inconveniences of prostatic resection are retrograde ejaculation and bladder neck stenosis in small prostates. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate in 22 patients and urethrotomy of the prostatic urethra in 27 with respect to postoperative retrograde ejaculation, persistent urinary symptomatology and maximal flow rates. After a mean followup of 25 months we concluded that internal urethrotomy of the prostatic urethra is the operation of choice in patients with a prostate of up to 30 gm.

Is routine dilation of the ureter necessary for ureteroscopy?

The results of transurethral ureteroscopic stone removal in 144 patients were reviewed. Patients were treated by two different techniques according to the dilation of the ureterovesical junction before the introduction of the ureteroscope. Group 1 was represented by 71 patients submitted to ureteral dilation and in group 2 there were 73 patients treated without ureteral dilation. There was only one failure in introducing the instrument without ureteral dilation. In patients submitted to transurethral ureteroscopy with previous ureteral dilation, the success of ureteroscopic stone removal was 91.6% and complications occurred in 6.9%, and, in the cases not submitted to ureteral dilation, the success rate was 99.4% and the complication rate 4.1%. The success rate achieved in removing upper third stones was 100.0% middle third 90.5% and lower third stones 95.6%. Of the 144 patients treated, 8 (5.5%) had ureteral injury, but only 1 (0.6%) needed open surgery. We do not believe that ureteral dilation prevents complications or improves the results of ureteroscopic lithotripsy.

Vasography: experimental study.

Vasography may cause stricture of the vas deferens. The probable causes of this obstruction are traumatic lesion at the puncture site and the radiological contrast material used. Because of this problem we performed an experimental study using Wistar rats, which were divided into four groups: Group A - Control, Group B - injection of a saline solution, Group C - hypaque injection, Group D - hypaque plus saline solution. According to the results obtained it was concluded that the needle puncture is not responsible for stricture of the vas deferens. Hypaque is responsible for 5% of strictures and the use of a saline solution to wash the vas did not show any benefit.

Endourologic approach of ureteral gunshot lesion.

We report a case which demonstrates that to approach an ureteral gunshot lesion endourologically may be an alternative to surgical intervention. We believe that drainage of a damaged ureter should, in selected cases, constitute the first option. This procedure often is successful, but may not be feasible in all cases. We do not believe that simple catheter drainage should replace standard surgical procedures. However, it presents a less invasive treatment alternative which still adheres to conventional surgical principles if a proper patient selection is made.