Assessment of sacral spinal excitability using stimulus-response curves of the bulbocavernosus reflex.

OBJECTIVE: To analyze and quantify sacral spinal excitability through bulbocavernosus reflex (BCR) stimulus-response curves. METHODS: Thirty subjects with upper motor neuron lesions (UMN) and nine controls were included in this prospective, monocentric study. Sacral spinal excitability was assessed using stimulus-response curves of the BCR, modeled at different bladder filling volumes relative to the desire to void (as defined by the International Continence Society) during a cystometry. Variations in α (i.e. the slope of the stimulus-response curve) were considered as an indicator of the modulation of sacral spinal excitability. RESULTS: In all subjects, α increased during bladder filling suggesting the modulation of spinal sacral excitability during the filling phase. This increase was over 30% in 96.7% of neurological subjects and 88.9% of controls. The increase was higher before the first sensation to void in the neurological population (163.15%), compared to controls, (29.91%), p < 0.001. CONCLUSIONS: We showed the possibility of using BCR stimulus-response curves to characterize sacral spinal response with an amplification of this response during bladder filling as well as a difference in this response amplification in patients with UMN in comparison with a control group. SIGNIFICANCE: BCR, through stimulus-response curves, might be an indicator of pelvic-perineal exaggerated reflex response and possibly a tool for evaluating treatment effectiveness.

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.

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.

Intermittent Self-catheterization in Older Adults: Predictors of Success for Technique Learning.

PURPOSE: The main goal of this retrospective study is to explore the predictors of success in learning clean intermittent self-catheterization (CISC) in patients over 65 years of age. The secondary goal is to assess whether in this population, the risk of failure to perform CISC is greater, compared with patients under 65 with similar pathologies. METHODS: All patients older than 65 consulting between January 2011 and January 2016 for learning CISC were included. A control population younger than 65 matching with sex, body mass index, and pathology was selected. RESULTS: One hundred sixty-nine of the 202 patients (83.7%) over 65 succeeded in learning CISC. Obesity (P<0.05), low pencil and paper test (PP test) (P<0.01) and low functional independence measure (FIM) (P<0.01) scores were risk factors of failure. No significant differences were found with sex or pathology. In multivariate analysis, low PP test perineum access (odds ratio [95% confidence interval], 2.30 [1.32-4.42]), low FIM motor (1.04 [1.01-1.08]), and FIM cognition (1.18 [1.03-1.37]) scores were independent factors of learning failure. Compared to control group, age over 65 was not predictive of failure (P=0.15). CONCLUSIONS: Our study shows that success in learning CISC does not depend on age but on difficulties in mobility, access to perineum and probably cognitive disorders.

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.

Posterior vaginal wall pull down maneuver: a clinical test to diagnose intrinsic sphincter deficiency in women suffering from genuine urinary stress incontinence.

OBJECTIVES: To assess the predictive value of a simple clinical test (posterior vaginal wall pull down maneuver) in the diagnosis of intrinsic sphincter deficiency. METHODS: The present prospective study included 62 women suffering from stress urinary incontinence. Every patient underwent a urogynecological examination including multichannel urodynamic testing (cystometry, urethral pressure profile, Valsalva Leak Point Pressure measurement) and a clinical examination including posterior vaginal wall pull down maneuver. Posterior vaginal wall pull down maneuver was carried out with the bladder filled with 400 mL of saline in a supine position, and was obtained by means of a split speculum allowing gentle pull down traction of the posterior vaginal wall. Posterior vaginal wall pull down maneuver was considered as positive when a urine leak was observed during the manoeuvre. Intrinsic sphincter deficiency was urodynamically defined by maximum urethral closure pressure ≤20 cmH2 O. Correlations between positive/negative posterior vaginal wall pull down maneuver and urodynamic intrinsic sphincter deficiency were calculated. RESULTS: There was a statistical correlation between age and low maximum urethral closure pressure (P < 0.0001), and between low maximum urethral closure pressure and positive posterior vaginal wall pull down maneuver (P < 0.0001). Regarding the intrinsic sphincter deficiency diagnosis, the posterior vaginal wall pull down maneuver positive predictive value was 94.67% and the negative predictive value was 95.4%, with a specificity of 97.6% and sensitivity of 90%. CONCLUSION: Posterior vaginal wall pull down maneuver is a reliable clinical test, easy to carry out, inexpensive and without significant risk. This test allows the diagnosis of intrinsic sphincter deficiency in women suffering from stress urinary incontinence, thus avoiding further invasive urodynamic testing (urethral pressure profile, Valsalva Leak Point Pressure measurement) in women with genuine stress urinary incontinence. Furthermore, it is helpful when choosing the type of sling procedure (retropubic vs transobturator) when a surgery is planned.

Pencil and paper test: a new tool to predict the ability of neurological patients to practice clean intermittent self-catheterization.

PURPOSE: We created and validated the new pencil and paper test, which allows assessment of the ability of patients with a neurological disorder to practice clean intermittent self-catheterization. MATERIALS AND METHODS: We developed a simple test including common gestures mimicking the usual maneuvers needed during clean intermittent self-catheterization, and involving the same cognitive and physical resources needed for this technique. We evaluated the test in 118 patients with a neurological condition. Instruments needed to perform the pencil and paper test are limited to a sheet of paper and a pencil. Each test item was quantified and graded with a total score of 15. A specific clean intermittent catheterization learning scale was used to classify the outcome of the ability to perform clean intermittent self-catheterization with a score range of 5--learning easy and self-catheterization complete to 0--learning impossible. RESULTS: Enrolled in the study were 118 patients with a neurological condition. There was strong correlation between the global pencil and paper test score, and the ability to perform clean intermittent self-catheterization, as evaluated by the learning scale (r = 0.82, p = 0.000091). At a test cutoff of 10 and a clean intermittent self-catheterization cutoff of 3, which was the limit needed to practice self-catheterization alone, the positive predictive value of the pencil and paper test was 85% and its negative predictive value was 94% (Cronbach's α = 0.88). CONCLUSIONS: The pencil and paper test is a valid way to predict the ability to practice clean intermittent self-catheterization in patients with a neurological disorder.

Urine leakage related to physical fatigue in women with urinary stress incontinence.

OBJECTIVE: To evaluate the frequency of urine leakage related to physical fatigue in women presenting with urinary stress incontinence using a specific questionnaire, and to assess its association with the Bristol Female Lower Urinary Tract Symptoms questionnaire and urodynamic findings. DESIGN: Prospective observational descriptive study. SETTING: University hospital (urodynamics laboratory). PARTICIPANTS: Sixty-one women presenting with urinary stress incontinence and 10 continent women. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The participants underwent urethral pressure profile measurement and completed a Bristol Female Lower Urinary Tract Symptoms questionnaire and a specific questionnaire focused on urine leakage related to physical fatigue. RESULTS: Twenty-three (37%) women with urinary stress incontinence claimed to exhibit urine leakage related to physical fatigue more often than one third of the time and 47% claimed to exhibit urinary leakage only after more than one cough. There was a positive correlation between the findings of the specific questionnaire and the presence of a sharp decrease in urethral pressure following repeated cough efforts: question #1 (P = 0.02); question #2 (P = 0.00002); question #3 (P = 0.04). CONCLUSION: There is a strong association between this questionnaire focused on urine leakage related to fatigue and the presence of a decrease in urethral pressure following repeated coughs.

External intercostal muscles and external anal sphincter electromyographic activity during coughing.

Few studies focused on concomitant electromyographic recordings of pelvic floor muscles and muscles involved in cough initiation. The objective of this study was to investigate the temporal course of external anal sphincter activation during coughing. Informed consent was obtained from ten healthy volunteers and ten women presenting with stress urinary incontinence (SUI). Simultaneously, recordings of electromyographic activity of external intercostal muscles (EIC EMGi) and external anal sphincter (EAS EMGi) during coughing have been performed. It was chosen to study intercostals muscles because they are synchronous to diaphragmatic muscle during cough initiation. Median (interquartile range) latency between the onset of the EAS EMGi and the onset of the EIC EMGi was -210 ms (-398; -135) and 0 ms (-30; +111.7) in volunteers' group and in SUI group, respectively (p = 0.0009). Abnormal temporal course of external anal sphincter activation is observed during coughing in women presenting with SUI compared to healthy volunteers.

Abnormal pelvic response to cough in women with stress urinary incontinence.

AIMS: To assess how muscular fatigue deteriorates the modulation of pelvic contraction during increasing cough efforts. Furthermore, we investigated the correlation between the temporal course of pelvic floor activation during cough. METHODS: Informed consent was obtained from 20 women presenting with SUI and 6 continent women (overactive bladder syndrome [OAB]). Bladder pressure (BP) and external anal sphincter electromyographic activity (EAS EMGi) were recorded concomitantly during increasing cough efforts. Modulation of pelvic contraction was assessed before and after two types of intense pelvic exercise (Exercise #1: 10 successive strong cough efforts; Exercise #2: 10 pelvic contractions followed by a maximal pelvic contraction) at 0, 200, and 400 ml of bladder filling. We have also recorded electromyographic activity of external intercostal (EIC) muscles. RESULTS: Whereas the Exercise 1 had no effect on modulation, the Exercise 2 altered significantly the modulation of pelvic contraction during increasing cough efforts (P = 0.043) only in women presenting with SUI. The bladder filling volume seems to not significantly modify this modulation (P = 0.12). Median latency between the onset of the EAS EMGi and the onset of the EIC EMGi was -470 and -60 msec in OAB group and in SUI group, respectively (P = 0.012). There was a good correlation between mean latency (default of EAS EMGi pre-activation) and an altered modulation of pelvic contraction during increasing cough efforts (P = 0.040). CONCLUSIONS: Some women with SUI exhibit an altered pattern of the PFM response during increasing coughing efforts. The lack of this modulation of PFM response to stress may be one of the pathophysiologic factors of SUI.

Autonomic nervous system activity during bladder filling assessed by heart rate variability analysis in women with idiopathic overactive bladder syndrome or stress urinary incontinence.

PURPOSE: Idiopathic overactive bladder syndrome is a common disorder, especially in women. Of various pathophysiological factors several studies suggest a specific dysfunction of the autonomic nervous system. To verify this hypothesis we compared heart rate variability parameters, which provide an analysis of autonomic function, in women with idiopathic overactive bladder syndrome to those in a reference population of women with stress urinary incontinence. MATERIALS AND METHODS: Diseases and medications that can perturb the autonomic nervous system were excluded. We included 7 women with pure stress urinary incontinence and 3 with isolated overactive bladder syndrome. Continuous echocardiogram recording was performed with the bladder emptied and during artificial bladder filling. High frequency variations of instantaneous heart rate represent parasympathetic activity, low frequency variations represent sympathetic activity and the low-to-high frequency ratio represents the autonomic balance. RESULTS: Heart rate variability parameters did not change significantly during bladder filling in women with stress urinary incontinence. In contrast, sympathetic tone in women with overactive bladder syndrome (low frequency) increased significantly at the end of bladder filling (p = 0.001), in parallel with a decrease in parasympathetic activity (high frequency) and a significant increase in the low-to-high frequency ratio (each p <0.001). Parasympathetic activity with the bladder emptied was significantly higher in the overactive bladder syndrome group (p = 0.017). CONCLUSIONS: This preliminary study demonstrates the predominance of parasympathetic activity with the bladder emptied and a preponderance of sympathetic activity at the end of bladder filling in women with overactive bladder syndrome. These results suggest dysfunction in the autonomic balance, as implied in idiopathic overactive bladder syndrome. Further studies in a larger population of patients with overactive bladder syndrome with reference to normal subjects free of urinary symptoms are necessary to confirm this hypothesis.

Decrease in urethral pressure following repeated cough efforts: a new concept for pathophysiology of stress urinary incontinence.

AIMS: To describe the decrease in maximum urethral closure pressure (MUCP) following repeated coughs in women with stress urinary incontinence (SUI). METHODS: MUCP was recorded at rest and after seven cough efforts in 70 women under age 40 referred for urodynamic investigation (47 women with SUI and 23 women without SUI). RESULTS: The intraclass correlation coefficient for repeatability was very good at 400 mL filling volume: 0.94 (95%CI: 0.85-0.98), as compared to the mean and standard-deviations of the MUCP measurements. A decrease in MUCP >20% after seven cough efforts was observed in 18(38%) patients in the SUI group and in just 1(4%) woman in the non-SUI group (P = 0.0069). CONCLUSIONS: Many women with SUI exhibit a sharp decrease in MUCP after repeated coughs. Many hypotheses may explain this phenomenon, including increased fatigue of the periurethral muscles.

Pelvic floor muscle activity during coughing: altered pattern in women with stress urinary incontinence.

OBJECTIVES: To assess the relationship between bladder pressure (BP) and pelvic floor muscle activity during coughing in women with stress urinary incontinence (SUI). METHODS: External anal sphincter integrated electromyographic activity (EAS-EMGi) was recorded in 21 women using pregelled surface electrodes. The relationship between BP and EAS-EMGi activity was assessed during four successive coughs at 0, 200, and 400 mL of filling. We also compared this relationship in 6 women presenting with SUI and 4 continent women. RESULTS: Among the considered models, a sigmoid relationship between EAS-EMGi and BP best described the data: EMGi = exp[a x (BP - b)]/(1 + exp[a x (BP - b)]). This relationship between EAS-EMGi and BP was significantly altered in women presenting with SUI (P <0.0001). CONCLUSIONS: Women with SUI exhibited an altered pattern of the pelvic floor muscle response during successive coughing efforts. The lack of this modulation of pelvic floor muscle response to stress might be one of the pathophysiologic factors of SUI.

External anal sphincter contraction during cough: not a simple spinal reflex.

AIMS: To assess whether the anal contraction during voluntary coughing is a simple spinal reflex-mediated activity or not. To address this question we studied the external intercostal (EIC) muscle activity and external anal sphincter (EAS) response to cough. MATERIALS AND METHODS: Electromyographic recordings were made from pre-gelled disposable surface electrodes. EAS electromyographic recordings were made from the EAS of the pelvic floor in 15 continent women all suffering from urgency and/or frequency without urge or stress urinary incontinence, and referred for urodynamic investigation. Electromyographic signal was immediately integrated (EMGi). The abdominal pressure was recorded with bladder and rectal pressure. EAS EMGi was recorded during successive voluntary cough. In three women, we have also recorded EIC EMGi activity since it is synchronous with diaphragmatic EMG activity during cough initiation. RESULTS: In all subjects, EAS EMGi activity precedes the onset of the abdominal pressure increase. The mean latency of EAS EMGi was 615 msec (+/-278). In the three subjects whose EMGi activity was recorded both on EAS and EIC, the onset of EAS EMGi activity occurred before the EIC EMGi activity (latency ranging from 40 to 780 msec) and before the increase in the abdominal pressure. CONCLUSIONS: The present study suggests that during coughing, EAS EMG activity increases before external intercostal muscle EMGi activity. The contraction of the EAS preceding the activation of muscles involved in coughing indicates that this response is not a result of a simple spinal reflex, but more likely the result of a more intricate reflex involving complex integrative centers.

Evidence of occult dysautonomia in Fowler's syndrome: alteration of cardiovascular autonomic function tests in female patients presenting with urinary retention.

OBJECTIVE: To assess the hypothesis that an occult impairment of the autonomic system might represent one of the mechanisms of urinary disturbance in Fowler's syndrome (FS), in which the pathophysiology of urinary retention is the predominant feature. PATIENTS AND METHODS: We prospectively investigated 10 women (mean age 43.7 years) with FS, diagnosed by assessing both voiding-phase dysfunction (complete or incomplete retention with a residual urine volume of >150 mL, and a maximum flow rate of <15 mL/s), abnormalities of striated urethral sphincter electromyography (decelerating bursts and complex repetitive discharges), the presence of polycystic ovaries and absence of any apparent usual causes (obstructive, neurological diseases). The women had a urodynamic investigation, electromyographic examination, cystoscopy, brain and spinal cord magnetic resonance imaging (MRI) and cardiovascular autonomic function tests (CAFTs, i.e. heart rate variability to deep breathing, cold-pressor test, Valsalva ratio, blood pressure response to standing, and sympathetic skin responses), for parasympathetic and sympathetic functions. Evidence of dysautonomia, as classically described, was defined by two or more positive CAFTs. RESULTS: The mean duration of symptoms was 7.9 years; there was urinary retention in six patients (one complete and five incomplete) and the other four complained of straining to void, diminished stream and hesitancy. Five patients were using intermittent self-catheterization. Six patients had two or more positive CAFTs and were considered to have dysautonomia. In all 10 women the clinical neurological and urological examinations were normal with no apparent clinical symptoms of dysautonomia (blurred vision, pupil abnormalities, clinical manifestations of postural hypotension, gastrointestinal symptoms). Brain and spinal cord MRI, cystoscopy, bladder and kidney ultrasonography, sacral-evoked latencies and cortical-evoked responses after pudendal nerve stimulation were normal. CONCLUSION: There was an occult impairment of the autonomic system in women with FS; this condition might be a pure bladder expression of a generalized but occult dysautonomia, which in some cases might be diagnosed using CAFTs.

Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. Urodynamic and electrophysiological study.

PURPOSE: Cough and more generally abdominal strain determine a pelvic floor contraction which allows an increase in sphincter pressure to prevent leakage during stress. Many electrophysiological studies have demonstrated this reflex (formally cough anal reflex). We postulated that the perineal muscle contraction following cough is not a simple binary response but proportional to the intensity of the cough. MATERIALS AND METHODS: A total of 16 women (mean age 52 years) without neurological disease or stress urinary incontinence, referred for frequency and urgency without urge incontinence, underwent urodynamic investigation. Vesical pressure was compared to electromyographic activity of the anal sphincter during 4 successive coughs of different intensity, namely gentle, moderate, strong and very strong efforts. These 4 graded coughs were repeated at 0, 100, 200, 300 and 400 ml of filling during cystometry. RESULTS: All patients were able to determine a graded cough at each level of filling. In all patients and at each level of filling a strict relationship between intravesical pressure (intensity of cough) and integrated electromyographic value was demonstrated. The greater the intensity of the cough the greater the electromyographic response of the anal sphincter. There is a strict correlation between vesical pressure and integrated electromyographic value at rest at O (R2 = 0.983) or at 100 ml (R2 = 0.970), 200 (R2 = 0.918) or 300 ml (R2 = 0.960). Bladder filling does not modify the responses. CONCLUSIONS: Pelvic floor muscle contraction increases with the importance of intra-abdominal pressure generated during stress. This gradual adaptation of pelvic floor muscles is probably 1 of the main factors which contributes to stress urinary and fecal continence in women. It must be preprogrammed by the central nervous system to maintain continence during various stresses.

Dissociation between electrical and mechanical bulbocavernosus reflexes.

AIMS: To record reflex motor responses, elicited by mechanical stimulation of the penis or clitoris, in each bulbocavernosus muscles and to compare left and right reflex pathways in normal subjects, then to compare electrical and mechanical responses in various neurological diseases. METHODS: Two groups of patients were studied: 22 patients without neurological disease considered as normal subjects; and 25 patients with neurological disease (three multiple sclerosis, six spina bifida, nine conus medullaris syndrome, three peripheral neuropathies, two lumbosacral lesions, one multisystem atrophy, and one syringomyelia). Electrical bulbocavernosus reflex (EBCR) was evoked by orthodromic stimulation of the dorsal nerve of the penis at the penile base or the clitoris. Mechanical bulbocavernosus reflex (MBCR) was elicited with an electromechanical hammer, tapping directly on the clitoris zone or on the ventral part of glans penis. For EBCR and MBCR, bulbocavernosus muscle contractions were successively recorded in the left and in the right side with a needle inserted under visual guidance. RESULTS: Mean left mechanical latency was 31.7 msec (SD = 4.5) and right one 31.6 msec (SD = 3.8). The reproducibility of the responses was excellent (P < 0.0001). ). The mean difference between left and right latencies was 2 msec (SD = 1.2). In the neurological group, 22 EBCR (six right, nine left, seven bilateral) and 19 MBCR (eight right, nine left, two bilateral) were considered abnormal. The mean reflex latencies in patients with neurological lesions (lower motor neuron lesions) were statistically longer (P < 0.0001) than in normal subjects. Exact concordance (side of lesion) between MBCR and EBCR was observed in 15/25 cases (60%), poor concordance (presence of a sacral reflex alteration) in 3/25 (12%) cases, and in 7/25 (28%) cases there was a significant difference between the two techniques. CONCLUSIONS: MBCR may provide a good alternative for electrical stimulation and can be used to evaluate urinary disorders when a neurological etiology is suspected. However, the presence of false negatives with MBCR suggest that it may be more useful as a screening test.

Bulbocavernosus muscle responses after suprapubic stimulation: analysis and measurement of suprapubic bulbocavernosus reflex latency.

Our objective was to describe pelvic floor responses with measurement of reflex latency after suprapubic mechanical stimulation. Twenty-one patients without neurological disease were studied. They were 14 women and seven men. The mean age was 51 (SD = 14.2). Motor responses were recorded with a needle electrode inserted in the left bulbocavernosus muscle. Stimulation was delivered with an electromechanical hammer, tapping directly on the suprapubic area. A polyphasic muscular response was always easily elicited in all patients. The man latency was 67.5 milliseconds (SD = 14.7). The reproducibility between the first and second mechanical responses was good with no statistical difference (r=0.966;P = 0.0001). In three patients who underwent cystometry, no rise in detrusor pressure was observed during mechanical stimulation of the suprapubic area. Our study clearly demonstrates a suprapubic bulbocavernosus reflex (SBR). Tapping the suprapubic area is a strong stimulus, reflexively mediated, used in the management of neurogenic bladder to determine a bladder contraction. However, the reflex consisting of pelvic floor muscle contraction after suprapubic stimulation was not specifically studied in humans. Many arguments can be put forth for a polysynaptic reflex (polyphasic response, habituation and short latency of the reflex, mean latency in the habitual values of R2 responses after electrical stimulation of the dorsal nerve of the penis). We hypothesize that the true stimulus is the stimulation of the bladder wall tensoreceptors, the integration level of the SBR is the sacral segments and the efferent limb the pudendal nerve, and afferent pathways could be conducted by pelvic nerve fibers. Competition between a preponderant (or exaggerated) SBR and a bladder contraction after suprapubic tapping may constitute an equivalent of detrusor-sphincter dyssynergia in some suprasacral bladders.