MULTIPLE SCLEROSIS AND THE UROLOGIST

Female sexuality in multiple sclerosis: the multidimensional nature of the problem and the intervention

Female sexual functioning is a complex process involving physiological, psychosocial and interpersonal factors. Sexual dysfunction (SD) is frequent (40-74%) among women with multiple sclerosis (MS), reflecting neurological dysfunction, psychological factors, depression, side effects of medications and physical manifestations of the disease, such as fatigue and muscle weakness. A conceptual model for sexual problems in MS characterizes three levels. Primary SD includes impaired libido, lubrication, and orgasm. Secondary SD is composed of limiting sexual expressions due to physical manifestations. Tertiary SD results from psychological, emotional, social, and cultural aspects. Sexual problems cause distress and may affect the family bond. Practical suggestions on initiation of discussion of sexual issues for MS patients are included in this review. Assessment and treatment of sexual problems should combine medical and psychosexual approaches and begin early after MS diagnosis. Intervention can be done by recognizing sexual needs, educating and providing information, by letting patients express their difficulties and referring them to specialists and other information resources.

Under treatment of overactive bladder symptoms in patients with multiple sclerosis: an ancillary analysis of the NARCOMS Patient Registry

PURPOSE

We describe the prevalence of overactive bladder symptoms in patients with multiple sclerosis as well as the rates of evaluation and treatment of urinary complaints.

MATERIALS AND METHODS

Data from the fall 2005 North American Research Committee On Multiple Sclerosis survey were examined, including the Urogenital Distress Inventory plus a nocturia question, the SF-12, and inquiries regarding urological care and treatments. Data were analyzed using descriptive statistics, chi-square and Student's t tests, ANOVA and multivariable logistic regression.

RESULTS

Of 16,858 surveys distributed 9,702 (58%) were completed. Participants with a surgically altered bladder were excluded from analysis (21). At least 1 moderate to severe urinary symptom (score of 2 or greater) was reported by 6,263 (65%) respondents. Increasing overactive bladder symptoms were correlated with longer disease duration (r = 0.135) and increasing physical disability (r = 0.291) (both p <0.001). Decreased quality of life was associated with increasing disability (p <0.001) and overactive bladder symptom score (p <0.001). Of patients with moderate to severe overactive bladder symptoms only 2,710 (43.3%) were evaluated by urology and 2,361 (51%) were treated with an anticholinergic medication. Treated patients more frequently reported leakage (p <0.001) and newer treatments were significantly underused (less than 10% total use). Catheter use was reported by 2,309 (36.8%) respondents, and was associated with greater disability, higher overactive bladder symptom score and reduced quality of life (all p <0.001).

CONCLUSIONS

This large scale study identified high rates of overactive bladder symptoms in patients with MS, and correlations with increasing disease duration and physical disability. Despite an increasing awareness of overactive bladder symptoms and the need for evaluation and treatment, many patients remain underserved.

Epidemiology of male sexual dysfunction

Male sexual dysfunction includes erectile dysfunction (ED), ejaculation disorders, orgasmic dysfunctions, and disorders of sexual interest/desire. Although current epidemiologic research supports the high prevalence of ED worldwide, incidence data are limited. Furthermore, prevalence data on other male sexual dysfunctions are also limited whereas incidence data are lacking. These epidemiologic data vary widely due to the different definitions used, the method of sampling, and the unknown value of the instruments used to assess sexual dysfunction. Many of the epidemiologic studies are old and associated with poor methodology. Although risk factors for ED are well described, there are almost no data for risk factors in other sexual dysfunctions. The impact of modification of risk factors in sexual dysfunctions is extremely interesting. To provide evidence-based data, there is an urgent need for new, properly designed epidemiological research.

Bladder dysfunction in multiple sclerosis

Multiple sclerosis (MS) is a relatively common disease of young adults. Patients with MS can have a wide range of symptoms and may develop significant disability. The cause of MS is unknown, but immunological mechanisms are important. In MS, the pathological features include prominent demyelination and inflammation, but there is also evidence of neurodegeneration. Bladder symptoms are common in MS. The bladder is under neural control, and bladder disturbance is usually attributed to demyelination or loss of axons from the neural pathways, particularly those in the spinal cord, that control the bladder. However, as with other symptoms in MS, the presence of bladder disturbance does not always correlate well with MRI lesions. We speculate that other possible causes of bladder dysfunction in MS might include the effects of circulating toxic factors. Urgency of micturition is prominent in MS, and better understanding of the receptors involved in bladder sensation suggests possible treatment strategies through inhibiting these receptors.

Urogenital dysfunction in patients with multiple sclerosis

The occurrence of urogenital dysfunction as an isolated early symptom in multiple sclerosis (MS) is rare, but the prevalence thereof becomes high with progression of disease. Lower urinary tract dysfunction may add to the cause of death (particularly through urinary infections), but both urinary and sexual dysfunction significantly affect quality of life of patients. Both storage and evacuation of urine may be affected by MS, and ultimatively the functional diagnosis can only be made by urodynamic testing. As upper urinary tract affection is, however, rare (and can be prevented by timely ultrasound imaging), a first stage diagnostics in the MS center by the neurologist and specialized nurse is appropriate. History, urine tests and post void residual urine determination (preferably by ultrasound) should provide necessary data for treatment of infections, and also symptomatic management of frequency, urgency and incontinence by bladder training, anticholinergics, and intermittent self catheterization (as indicated); the referral to urologist may be reserved for patients who fail first line treatment. Treatment in the late stages of MS is as yet little researched, but eventually a suprapubic catheter is the preferred method of bladder emptying. Sexual dysfunction should be actively sought in MS patients (in men erectile and ejaculation dysfunction, in women deficient lubrication and genital hyper- or hyposensitivity are frequent). Clinical examination contributes little to clarification of neurogenic sexual dysfunction, but defines the extent of other deficits due to MS, which may be relevant for sexual counseling (spasticity, sensory loss). Sildenafil has been demonstrated to be effective in treatment of men, but not in women. Other management options exist, and the doctor and nurse in the MS center should be proactive in providing first line counseling and management.

Evaluating potential therapies for bladder dysfunction in a mouse model of multiple sclerosis with high-resolution ultrasonography

Background

In multiple sclerosis (MS), demyelinating and neurodegenerative lesions develop throughout the central nervous system, which result in a loss of neurotransmission. As a result, people with MS exhibit a wide range of symptoms including dysfunction of the bladder, which can lead to urinary incontinence or retention. Such signs can develop in animal models of MS. Current assessments of bladder properties in animal models are generally invasive, electrophysiological techniques.

Objective

The use of a non-invasive, ultrasound system for measuring bladder volume in a mouse model of MS.

Methods

Chronic relapsing experimental autoimmune encephalomyelitis was induced in mice. The bladder volume was assessed using ultrasonography, during the disease course and following therapy with bethanechol chloride.

Results

It was demonstrated that volumes obtained ultrasonically positively-correlated (r = 0.960) with the urine volumes obtained by manual expression. It was also shown for the first time that bladder size increased significantly in mice with residual neurological deficit. Indeed, this increase in bladder size showed a strong, positive-correlation (r = 0.951) with the hind limb spasticity. Following treatment with bethanechol chloride, bladder volume significantly decreased in mice with chronic experimental autoimmune encephalomyelitis.

Conclusion

This study demonstrates a novel outcome measure in experimental MS that allows; repeated, non-invasive, high resolution ultrasonic monitoring of bladder function.

Multiple sclerosis

Multiple sclerosis is the most common disabling neurologic disease affecting young adults and adolescents in the United States. The first objective of this article is to familiarize nonspecialists with the cardinal features of multiple sclerosis and our current understanding of its etiology, epidemiology, and natural history. The second objective is to explain the approach to diagnosis. The third is to clarify current evidence-based treatment strategies and their roles in disease modification. The overall goal is to facilitate the timely evaluation and confirmation of diagnosis and enhance effective management through collaboration among primary physicians, neurologists, and other care providers who are confronted with these formidably challenging patients.

Bladder dysfunction in mice with experimental autoimmune encephalomyelitis

The vast majority of patients with multiple sclerosis (MS) develop bladder control problems including urgency to urinate, urinary incontinence, frequency of urination, and retention of urine. Over 60% of MS patients show detrusor-sphincter dyssynergia, an abnormality characterized by obstruction of urinary outflow as a result of discoordinated contraction of the urethral sphincter muscle and the bladder detrusor muscle. In the current study we examined bladder function in female SWXJ mice with different defined levels of neurological impairment following induction of experimental autoimmune encephalomyelitis (EAE), an animal model of central nervous system inflammation widely used in MS research. We found that EAE mice develop profound bladder dysfunction characterized by significantly increased micturition frequencies and significantly decreased urine output per micturition. Moreover, we found that the severity of bladder abnormalities in EAE mice was directly related to the severity of clinical EAE and neurologic disability. Our study is the first to show and characterize micturition abnormalities in EAE mice thereby providing a most useful model system for understanding and treating neurogenic bladder.

Anticholinergics for urinary symptoms in multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is the commonest physically disabling chronic neurological disease affecting young people. Urinary symptoms are present in about 68% of people with MS but their basis has a number of potential aetiologies that can change with time.

OBJECTIVES

To assess the absolute and comparative efficacy, tolerability and safety of anticholinergic agents in MS patients.

SEARCH STRATEGY

We searched the Cochrane Multiple Sclerosis Group Specialised Trials Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue1), MEDLINE (January 1966 to January 2008), EMBASE (January 1974 to January 2008), supplemented with search of reference lists, personal communication with authors and relevant drug manufacturers.

SELECTION CRITERIA

Randomised trials and cross-over trials (blinded and unblinded) that are either placebo-controlled or comparing two or more treatments.

DATA COLLECTION AND ANALYSIS

All four review authors independently assessed eligibility and trial quality, and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Our search strategy identified 33 articles of which thirty were excluded. Three single centre trials were included. No details were given regarding randomisation and blinding in the first two trials but side effects were frequent with all treatments.The first (Hebjorn 1977) was a double blind randomised crossover trial. Thirty four persons with MS received three drugs Methantheline Bromide, Flavoxate Chloride and Meladrazine Tartrate each for 14 days, washout periods were not mentioned. Median volume measurements at the first bladder contraction were statistically significant at a 5% level for Methantheline Bromide only compared to no treatment.The second (Gajewski 1986) was a prospective parallel group randomised study. Thirty four persons with MS were treated for 6-8 weeks with Oxybutynin (19 subjects) or Propantheline (15 subjects). For frequency, nocturia, urgency, and urge incontinence differences in symptom grade in favour of Oxybutynin were found. However, only for frequency the difference was statistically significant at 5% level.The third (Fader 2007) was a double blind crossover trial. Sixty four persons with MS received oral Oxybutynin or intravesical Atropine for 14 days. Details of randomisation and blinding were given. There was no significant difference between the two treatments in any efficacy outcome measure. Side effects and QOL scores showed significant differences in favour of atropine.

AUTHORS' CONCLUSIONS

From the available evidence we cannot advocate the use of anticholinergics in MS.

Augmentation cystoplasty: what are the indications?

Augmentation cystoplasty has been studied and performed by urologists for more than 100 years. Although specific indications, techniques, and materials used have undergone major changes and revisions during this period, the general concepts have remained the same. Bladder augmentation increases the bladder's storage capacity. Specific indications include structurally diminished bladder capacity, neurogenically incapacitated bladder, special circumstances of overactive bladder, and interstitial cystitis. This article briefly reviews techniques including laparoscopic and extraperitoneal approaches. Most common long-term consequences of bladder augmentation including chronic infections, bladder stones, perforation, and malignancy are described. Overall, we demonstrate that in appropriately selected patients, bladder augmentation presents an excellent treatment option to improve bladder capacity, achieve socially acceptable continence, and stabilize renal function.

Analysis of the upper urinary tract function in multiple sclerosis patients

AIMS

The objective of this study was to analyse the upper urinary tract (UT) function in a group of consecutive multiple sclerosis (MS) patients, who had not previously been treated by urologist.

MATERIALS AND METHODS

Ninety-two MS patients suffering from lower UT dysfunction were included in the study. The group of patients consisted of 69 women and 23 men. The average Expanded Disability Status Scale (EDSS) score in our group was 4.29 (0-8.5). Functional examination of the kidneys using assessment of creatinine clearance and morphological examination of the kidneys using ultrasound was performed in all patients. Analysis of the upper UT function is presented.

RESULTS

The average serum creatinine clearance in our group was 132.84 ml/min/1.73 m(2) (46.8-510). Lower levels than normal were found in three patients (3.3%). Abnormal ultrasound findings were recorded in five patients (5.4%). The creatinine clearance was correlated with the clinical subtype of MS, the severity expressed by EDSS, the urodynamic parameters, the duration of the disease, the duration of the symptoms of lower UT and the EDSS score. We did not find a statistically significant correlation for any of these parameters.

CONCLUSIONS

Our results suggest that impairment of the upper UT function is exceptional in MS patients.

Female sexual dysfunction: classification, pathophysiology, and management

Female sexual dysfunction is a prevalent problem in the general community; however, it has not been studied as extensively as male sexual dysfunction. Female sexual dysfunction is a common complication after most pelvic surgeries. With the introduction of screening programs, most pelvic malignancies are detected at earlier stages and in younger patients. Sexual dysfunction is a major quality-of-life issue in these young women. Hysterectomy (simple or radical) is the most common type of pelvic surgery in women and is one of the most important causes of female sexual dysfunction. Additionally, female sexual dysfunction is an important issue after urologic (radical cystectomy) and colorectal surgeries (simple and radical proctocolectomy). Sexual dysfunction is a common problem among postmenopausal women. Modifications in the surgical technique (nerve sparing) are rapidly evolving in the field of urology and colorectal surgery, which will be soon followed by modifications in the field of gynecologic surgery. In this article we summarize the pathophysiology and classification of female sexual dysfunction, with special emphasis on the relationship between female sexual dysfunction and pelvic surgeries.

Chapitre C - Troubles vésico-sphinctériens et sclérose en plaques

Multiple sclerosis (MS) is a neurological disease characterized by multiple demyelinating lesions disseminated throughout the central nervous system (nerve conduction block). The management of these patients requires a perfect knowledge of the natural history of the disease. In this article, the authors review the literature to identify the most frequent voiding disorders observed in this disease and then study the diagnostic and therapeutic modalities and the optimal modalities of follow-up in these patients, in view of the risk of various urological complications.

Women with Voiding Dysfunction Secondary to Bladder Outlet Dyssynergia in the Setting of Multiple Sclerosis Do Not Demonstrate Significantly Elevated Intravesical Pressures

OBJECTIVES

Elevated intravesical pressures secondary to detrusor sphincter dyssynergia result in an increased risk of renal deterioration in patients with cervical and thoracic spinal cord injury, although the risk is less clear in patients with multiple sclerosis (MS). The purpose of this study was to study the impact of a closed bladder outlet on intravesical pressures in patients with MS.

METHODS

The data from all patients with MS referred for urologic evaluation were prospectively entered into a urodynamic database. Patients were advised to undergo full multichannel urodynamic studies. Among the patients with detrusor overactivity, the detrusor pressures were compared between the patients with and without bladder outlet dyssynergia (BOD).

RESULTS

Of the 143 patients referred for evaluation and entered into the database, 127 were women. Of the 127 women, 108 completed the urodynamic studies. Overall, 62 (57%) of the 108 women had detrusor overactivity, 30 of whom had coexisting BOD. The detrusor pressures during bladder contractions were greater in patients with BOD, although not significantly. For example, the maximal detrusor pressure (49.9 +/- 19.5 cm H2O versus 43.7 +/- 23.0 cm H2O, P = 0.25) and detrusor pressure at maximal flow (37.9 +/- 15.7 cm H2O versus 33.5 +/- 16.3 cm H2O, P = 0.93) were both only slightly greater in patients with BOD.

CONCLUSIONS

Nonsignificant elevations in detrusor pressures were noted in patients with MS and BOD. The lack of significant elevations in detrusor pressure among the patients with MS, detrusor overactivity, and BOD could account for the relatively low incidence of upper tract damage in women with MS.

The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines

Vesicourethral dysfunction is very frequent in multiple sclerosis (MS) and has functional consequences for patients' quality of life and also an organic impact following complications of the neurogenic bladder on the upper urinary tract. While the functional impact and its management are well documented in the literature, the organic impact remains underestimated and there are no consensual practical guidelines for the screening and prevention of MS neurogenic bladder complications. The aim of this review of the literature, focused on identifying the risk factors of urinary tract complications in MS, is to put forward well informed considerations to help in the definition of practical guidelines for the follow-up of the neurogenic bladder in MS in order to improve its prevention and patient management. Four main risk factors have been identified for upper urinary tract damage: the duration of MS, the presence of an indwelling catheter, high-amplitude neurogenic detrusor contractions and permanent high detrusor pressure. Detrusor-sphincter dyssynergia, age over 50 and male sex may form three additional risk factors. Recommendations for long-term urological follow-up, taking into account these specific risks are constructed according to the procedures recommended by the French Health Authorities.

Electrical stimulation of sacral dermatomes in multiple sclerosis patients with neurogenic detrusor overactivity

AIMS

Transcutaneous electrical stimulation of the dorsal penile/clitoral nerve (DPN) has been shown to suppress detrusor contractions in patients with neurogenic detrusor overactivity (NDO). However, the long-term use of surface electrodes in the genital region may not be well tolerated and may introduce hygienic challenges. The aim of this study was to assess whether electrical stimulation of the sacral dermatomes could suppress detrusor contractions in multiple sclerosis (MS) patients with NDO, hereby providing an alternative to DPN stimulation.

MATERIALS AND METHODS

A total of 14 MS patients (8 M, 6 F) with low bladder capacity (<300 ml) and a recent urodynamic study showing detrusor overactivity incontinence participated in the study. Three successive slow fill cystometries (16 ml/min) were carried out in each patient. The first filling served as control filling where no stimulation was applied. In the second and third filling electrical stimulation of either the DPN or sacral dermatomes was applied automatically whenever the detrusor pressure exceeded 10 cmH2O.

RESULTS

The control filling showed detrusor overactivity in 12 of the 14 patients. In 10 of the 12 patients one or more detrusor contractions could be suppressed with DPN stimulation. Electrical stimulation of the sacral dermatomes failed to suppress detrusor contractions in all patients.

CONCLUSIONS

Although therapeutic effects may be present from stimulation of the sacral dermatomes, we were unable to demonstrate any acute effects during urodynamics. For this reason stimulation of the sacral dermatomes is not an option in a system that relies on the acute suppression of a detrusor contraction.

Characterization and restoration of altered inhibitory and excitatory control of micturition reflex in experimental autoimmune encephalomyelitis in rats

Multiple sclerosis (MS) is characterized by inflammatory lesions throughout the central nervous system. Spinal cord inflammation correlates with many neurological defecits. Most MS patients suffer from micturition dysfunction with urinary incontinence and difficulty in emptying the bladder. In experimental autoimmune encephalomyelitis (EAE) induced in female Lewis rats, a model of MS, we investigated at distinct clinical severity scores the micturition reflex by cystometrograms. All rats presenting symptomatic EAE suffered from micturition reflex alterations with either detrusor areflexia or hyperactivity. During pre-symptomatic EAE, a majority of rats presented with detrusor areflexia, whereas at onset of clinical EAE, detrusor hyperactivity was predominant. During progression of EAE, detrusor areflexia and hyperactivity were equally expressed. Bladder hyperactivity was suppressed by activation of glycine and GABA receptors in the lumbosacral spinal cord with an order of potency: glycine > GABA(B) > GABA(A). Detrusor areflexia was transformed into detrusor hyperactivity by blocking glycine and GABA receptors. Spinalization abolished bladder activity in rats presenting detrusor hyperactivity and failed to induce activity in detrusor areflexia. Altogether, the results reveal an exaggerated descending excitatory control in both detrusor reflex alterations. In detrusor areflexia, a strong segmental inhibition dominates this excitatory control. As in treatment of MS, electrical stimulation of sacral roots reduced detrusor hyperactivity in EAE. Blockade of glycine receptors in the lumbosacral spinal cord suppressed the stimulation-induced inhibitory effect. Our data help to better understand bladder dysfunction and treatment mechanisms to suppress detrusor hyperactivity in MS.

Event driven electrical stimulation of the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in multiple sclerosis

AIMS

The aim of this study was to evaluate the effect of automatic event driven electrical stimulation on the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in patients suffering from Multiple Sclerosis.

METHODS

A total of 10 patients participated in the study. Detrusor pressure was recorded during physiological filling of the bladder and electrical stimulation was applied with surface electrodes whenever the detrusor pressure exceeded 10 cm H(2)O.

RESULTS

In seven of the eight patients, where neurogenic detrusor overactivity was observed an average of 12 detrusor contractions could be inhibited by stimulation. In one patient, however, stimulation failed to inhibit the detrusor contractions. The average increase in bladder volume from first suppressed detrusor contraction until leakage was 94% (range: 22-366%). On average, the time from first suppressed contraction until leakage was 15 min and 50 sec (range: 4 min 58 sec-32 min 5 sec) with an average physiological filling rate of 8 ml/min. Urgency was effectively suppressed at the onset of stimulation.

CONCLUSIONS

The results indicate that involuntary detrusor contractions in patients with multiple sclerosis can effectively be inhibited with event driven stimulation, hereby improving bladder capacity and reducing the number of incontinence episodes. However, the used method for detecting detrusor contractions is not suitable in a chronic setting and alternative techniques needs to be investigated if stimulation should be applied automatically.

Acute urodynamic effects of posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with MS

OBJECTIVES

The aim of this study was to investigate whether acute electrical stimulation of the posterior tibial nerve could suppress detrusor contractions in multiple sclerosis (MS) patients with neurogenic detrusor overactivity.

METHODS

Two successive slow-fill cystometries (16 ml/min) were carried out in eight MS patients with neurogenic detrusor overactivity. The first filling served as control without stimulation. In the second filling, electrical stimulation using needle electrodes was applied automatically to the posterior tibial nerve when the detrusor pressure exceeded 10 cm H(2)O. An additional filling in which the needle electrodes were replaced by surface electrodes was carried out in three patients.

RESULTS

The control filling showed detrusor overactivity in eight patients, but electrical stimulation of the posterior tibial nerve failed to suppress detrusor contractions in all tested patients.

CONCLUSIONS

Although neuromodulative effects may be obtained with therapeutic electrical stimulation of the posterior tibial nerve, no acute effects were demonstrated. For this reason, electrical stimulation of pudendal afferents remains the only option if acute suppression of a detrusor contraction is required.

Quality of life in women with multiple sclerosis and overactive bladder syndrome

The aim of this study was to evaluate the impact of symptoms of overactive bladder syndrome (OAB) on the quality of life (QoL) in female patients with or without multiple sclerosis (MS) and their correlation with findings from urodynamics (UDS). We enrolled 107 female patients with clinically definite MS and urinary symptoms of OAB. One-hundred female patients with similar OAB symptoms were used as a control group. Data on OAB symptoms, onset and progression, and results of any previous investigation were obtained, and any urinary complications were documented. A complete UDS investigation was performed. Health status assessment was obtained using the Kings Health Questionnaire. Results showed that urinary symptoms had a greater impact on the QoL in patients with MS. Nevertheless, the perception of the severity of these symptoms was minor in the MS group compared to the control group. No significant correlations were found between the dysfunctions as detected by UDS and the OAB symptoms in both groups. Recurrent urinary tract infections represented the main complication in the study population. In conclusion, OAB symptoms have a major impact on the QoL in patients with MS, even if their perception of QoL impairment remains limited. Optimal management in these subjects should include a complete UDS assessment.

Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis

AIMS

We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms.

METHODS

Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention.

RESULTS

There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high.

CONCLUSIONS

BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.

Therapy Insight: bladder dysfunction associated with multiple sclerosis

Bladder dysfunction is a common problem for patients with multiple sclerosis. The severity of symptoms often correlate with the degree of spinal cord involvement and, hence, the patient's general level of disability. The emphasis of management is now mainly medical and is increasingly offered by nonurologists. Treatments can be highly effective, relieving patients of what are otherwise very troublesome symptoms that would compound their neurological disability. This article gives an overview of the neural control of the bladder, followed by an explanation of the pathophysiology of detrusor overactivity secondary to neurological disease. A review of methods available for treating bladder dysfunction in multiple sclerosis then follows. The treatment options for this disorder are largely medical and include established first-line measures such as anticholinergics, clean intermittent self-catheterization and the use of desmopressin, as well as potential second-line agents, such as cannabinoids, intravesical vanilloids and intradetrusor botulinum neurotoxin type A. The diminishing role of surgical intervention is also discussed.

Urodynamic distinctions between idiopathic detrusor overactivity and detrusor overactivity secondary to multiple sclerosis

OBJECTIVES

To evaluate the urodynamic characteristics of neurogenic detrusor overactivity (NDO) secondary to multiple sclerosis (MS) compared with idiopathic DO (IDO) to determine whether urodynamic distinctions could differentiate the different etiologies of DO.

METHODS

The urodynamic characteristics of DO in women with MS (n = 54) were compared with the overactive contractions found in women with lower urinary tract symptoms and IDO (n = 42). Among other parameters, the amplitude of the first overactive contraction, maximal detrusor contraction, and threshold volume for the first overactive contraction were evaluated to assess the DO severity. A sensitivity analysis using cutoff values determined from those urodynamic parameters that differed between the patient groups is presented.

RESULTS

The amplitude of the first overactive contraction was statistically greater in the patients with MS and NDO compared with patients with IDO (28.3 cm H2O versus 20.5 cm H2O, P = 0.003), as was the maximal detrusor contraction (46.4 cm H2O versus 30.8 cm H2O, P = 0.002). The threshold volume for DO was greater among patients with NDO (186.8 mL versus 150.5 mL, P = 0.037), likely secondary to the elevated postvoid residual urine volume noted among patients with MS (P = 0.049). Using a cutoff value of 30 cm H2O for amplitude of the first overactive contraction achieved a positive predictive value of 88% for identifying MS in our data set.

CONCLUSIONS

The urodynamic characteristics of NDO differed significantly from those of IDO. Additional investigation is required to determine whether these differences are due to neurogenic influences directly on the detrusor muscle through aberrant innervation or by other mechanisms, such as enhanced outlet resistance during voiding.

The effect of cannabis on urge incontinence in patients with multiple sclerosis: a multicentre, randomised placebo-controlled trial (CAMS-LUTS)

OBJECTIVE

To test whether cannabinoids reduce urge incontinence episodes without affecting voiding in patients with multiple sclerosis. This was part of the multicentre trial of the Cannabinoids in Multiple Sclerosis (CAMS) study.

SUBJECTS AND METHODS

The CAMS study randomised 630 patients to receive oral administration of cannabis extract, Delta(9)-tetrahydrocannabinol (THC) or matched placebo. For this substudy subjects completed incontinence diaries.

RESULTS

All three groups showed a significant reduction, p<0.01, in adjusted episode rate (i.e. correcting for baseline imbalance) from baseline to the end of treatment: cannabis extract, 38%; THC, 33%; and placebo, 18%. Both active treatments showed significant effects over placebo (cannabis extract, p=0.005; THC, p=0.039).

CONCLUSION

The findings are suggestive of a clinical effect of cannabis on incontinence episodes in patients with MS. This is in contrast to the negative finding of the CAMS study, where no difference was seen in the primary outcome of spasticity.

Botox in urology

Lower urinary tract dysfunction is one of the challenging problems facing urologists and patients. Several treatment trials have been introduced in the literature, but none has proven to be as effective as being a gold standard treatment for such conditions. We reviewed the literature regarding the use of botulinum toxin (BTx) type A as a current treatment of lower urinary tract conditions described below. The toxin has been shown to be safe and effective in the treatment of conditions caused by increased muscle tonicity. Indications for the urological use of BTx and future applications are also considered.

Clinical Evaluation of Erectile Dysfunction in the Era of PDE-5 Inhibitors

Erectile dysfunction (ED) is a common disorder that has gained attention since the introduction of relatively safe treatment with phosphodiesterase-5 inhibitors. ED is a multi-factorial disorder and a common presentation for several systemic illnesses,particularly vascular occlusive diseases. The clinical evaluation of ED should be thorough and systematic, with attention to the appropriate use of sexual symptom questionnaires and symptom scales, detailed medical and sexual history, physical examination,and basic screening laboratory tests. Patients should be referred for specialized evaluations when appropriate. The clinician must be familiar with the pathophysiologic mechanisms of ED, its associations with other systemic diseases, the indications for specialist referrals, and the role of specialized testing to diagnose and treat this disorder effectively.

Incidence of upper tract abnormalities in patients with neurovesical dysfunction secondary to multiple sclerosis: Analysis of risk factors at initial urologic evaluation

OBJECTIVES

To determine the incidence of upper tract abnormalities on renal ultrasonography in patients with multiple sclerosis (MS) referred for urologic evaluation, as well as to identify any risk factors present on the basis of the historical information and urodynamic findings.

METHODS

Data were derived from all patients with MS referred to the neurourology clinic during a 4-year period. The database was specifically queried for patients found to have upper tract abnormalities on screening renal ultrasonography. Demographic parameters, as well as laboratory values (creatinine) and urodynamic results, were evaluated for risk factors associated with abnormal upper tract findings.

RESULTS

Of the 113 patients referred and evaluated, 66 completed both urodynamic testing and renal ultrasonography. Eleven (16.7%) had abnormal ultrasound findings, with focal caliectasis the most common finding. No demographic parameter (age, sex, time since MS diagnosis, MS pattern) was associated with a greater likelihood of abnormal renal ultrasonography on univariate analysis. Neither serum creatinine nor any urodynamic finding (including the presence of dyssynergia or the threshold and amplitude of detrusor overactivity) was associated with abnormal renal ultrasound findings.

CONCLUSIONS

No patients in our series had any indication of obstructive uropathy more severe than mild hydronephrosis. Of the 16.7% of patients with any abnormal findings, most were noted to have minor caliectasis, likely to be of little clinical significance. Although no factors identifying patients at risk of renal abnormalities at presentation were found, ongoing evaluation of patients with baseline findings will serve to identify those at risk of progression.

ORIGINAL RESEARCH—PATHOPHYSIOLOGY: Clinical Biologic Pathophysiologies of Women's Sexual Dysfunction

INTRODUCTION

Data concerning the biologic pathophysiology of desire, arousal, and orgasm in women are limited.

AIM

To gain knowledge of biologic pathophysiology of female sexual function. METHODS. To provide state-of-the-art knowledge concerning female sexual dysfunction, representing the opinions of seven experts from five countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

An International Consultation in alliance with key urological and sexual medicine societies convened over 200 multidisciplinary specialists from 60 countries into 17 consultation committees. The aims, goals and intentions of each committee were defined. Expert opinion was based on grading of evidence-based medical literature, extensive internal committee dialogue, open presentation, and debate.

RESULTS

Three critical physiologic requirements, including intact sex steroids, autonomic/somatic nerves, and arterial inflow/perfusion pressure to women's genital organs play fundamental roles in maintaining women's sexual function. Despite this, there are nominal data supporting a direct pathophysiologic involvement of abnormal sex steroid values, and/or damage/injury to neurologic and/or blood flow integrity in women with problems in sexual desire, arousal, and/or orgasm. This summary details the available literature concerning hormonal, neurologic, and vascular organic pathophysiologies of women's sexual dysfunctions.

CONCLUSIONS

Additional research on clinical pathophysiologies in women's sexual dysfunction is needed. This chapter encompasses data presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.

Mechanisms of Disease: central nervous system involvement in overactive bladder syndrome

The pathophysiology of overactive bladder syndrome (OABS) and detrusor overactivity (DO) is complex and involves both peripheral and central nervous system (CNS) factors. Central in OABS is urgency, the pathophysiology of which is unknown. Increased afferent activity, decreased capacity to process afferent information, decreased suprapontine inhibition, and increased sensitivity to contraction-mediating transmitters are all potential causes of DO and OABS. Because both urgency and initiation of the micturition reflex depend on afferent input from the lower urinary tract, it seems logical that in the search for new therapies for DO/OABS, afferent functions and central control of afferent functions are targets of interest. Voiding and storage reflexes involve several transmitters and transmitter systems that could be targets for the development of drugs that control DO/OABS. Perturbations of these systems are found in CNS disorders associated with DO/OAB, such as stroke, Parkinson's disease, spinal cord injury and multiple sclerosis. This short overview focuses on the afferent pathways and on how the transmitter systems that control micturition can be perturbed by disease to give rise to DO/OABS.

Effects of TAK-802, a novel acetylcholinesterase inhibitor, and various cholinomimetics on the urodynamic characteristics in anesthetized guinea pigs

In the present study, we investigated the effects of cholinomimetic drugs on the urodynamic characteristics in anesthetized guinea pigs. 8-[3-[1-[(3-fluorophenyl)methyl]-4-piperidinyl]-1-oxopropyl]-1,2,5,6-tetrahydro-4H-pyrrolo[3,2,1-ij]quinolin-4-one (TAK-802), a novel acetylcholinesterase inhibitor, (0.003-0.03 mg/kg, i.v.) increased the voided volume and the maximum flow rate without affecting either the intravesical pressure or the bladder compliance. Distigmine (0.03-0.3 mg/kg, i.v.) and neostigmine (0.01-0.1 mg/kg, i.v.), both carbamate acetylcholinesterase inhibitors, while not increasing the maximum flow rate, increased the intravesical pressure at the maximum flow rate. They also decreased the bladder compliance. Bethanechol (0.1-1 mg/kg, i.v.), a muscarinic receptor agonist, decreased the voided volume and the bladder compliance but did not affect the maximum flow rate. TAK-802 did not affect the intraurethral pressure at doses of up to 0.03 mg/kg in anesthetized guinea pigs. Distigmine increased the intraurethral pressure when administered at the dose of 0.3 mg/kg, and the effect was completely abolished by pretreatment with d-tubocurarine. These results suggest that TAK-802 reinforces the bladder-voiding functions by increasing the bladder contractility without decreasing the storage function. On the other hand, carbamate acetylcholinesterase inhibitors not only deteriorate the voiding function by inducing contraction of the external urethral sphincter muscle, resulting in increasing the urethral resistance, but also cause deterioration of the storage function. Bethanechol obviously decreased the bladder capacity, possibly due to a direct contractile effect on the detrusor smooth muscle. TAK-802 may therefore be a more useful drug than either carbamate acetylcholinesterase inhibitors or muscarinic receptor agonists in the treatment of voiding dysfunction associated with impaired detrusor contractility.

Retrograde labeling of mouse spinal descending tracts by a recombinant adenovirus

The present study tested whether a gene-transfer based upon the retrograde axonal transport of the lacZ adenovirus is effective in the spinal descending tracts of the adult mouse. A small volume of a replication-defective recombinant adenovirus encoding E. coli beta-galactosidase was injected into the upper lumbar cord, and, seven days later, the mice were transcardially perfused by a fixative solution. X-gal staining of coronal or sagittal sections of the spinal cord and the brain revealed that many sites of origin for rubrospinal, vestibulospinal, and reticulospinal tracts were retrogradely labeled, whereas few of the corticospinal tract neurons were retrogradely labeled. Ependymal cells surrounding the central canal of the spinal cord, which were located far from the injection site, showed a high expression of beta-galactosidase activity. Motoneurons around the injection site were strongly stained by X-gal staining, and their axons in the ventral root were anterogradely labeled. Afferent fibers in the dorsal root were labeled by the transganglionic transport of beta-galactosidase. To examine the efficacy of the uptake and retrograde transport of HRP and adenovirus, we injected a mixed solution of 10% HRP and recombinant adenovirus. The number of HRP-labeled corticospinal neurons overwhelmed the number of X-gal stained ones, while the numbers of HRP-labeled rubrospinal and subcoeruleus-spinal neurons were smaller in comparison with the numbers of beta-galactosidase-positive counterparts. The present study revealed that the origins for the spinal descending tracts except for corticospinal neurons could be efficiently gene-transferred by the retrograde infection of a recombinant adenovirus. Such a difference in efficacy of retrograde infection among the spinal descending tracts is practically important when an adenovirus-mediated gene transfer is designed to treat certain neurological diseases affecting the spinal descending tracts.

CNS involvement in overactive bladder: pathophysiology and opportunities for pharmacological intervention

The pathophysiology of overactive bladder (OAB) syndrome is complex, and involves both peripheral and CNS factors. Several CNS disorders are associated with OAB, e.g. stroke, spinal cord injury, Parkinson's disease and multiple sclerosis, and in each disorder the pathophysiology of OAB can be multifactorial. Irrespective of cause or pathophysiology of OAB, antimuscarinic drugs are the first line of pharmacological treatment. However, adverse effects and limited efficacy makes alternative therapeutic principles desirable. Most alternative drugs used for the treatment of OAB have a peripheral site of action, mainly affecting efferent or afferent neurotransmission or the detrusor muscle itself. New targets for pharmacological intervention may be found in the CNS. Several CNS transmitters/transmitter systems are known to be involved in micturition control, but few drugs with a defined CNS site of action (e.g. baclofen, imipramine and duloxetine) have been used for the treatment of voiding disorders. GABA, glutamate, opioid, serotonin, noradrenaline (norepinephrine), and dopamine receptors and mechanisms are known to influence micturition, and drugs influencing these systems could potentially be developed for the treatment of OAB. Preclinical studies in different animal models have shown that modulation of normal micturition and detrusor overactivity by drugs acting within the spinal cord or supraspinally is possible. Promising results have been obtained in such models, e.g. with drugs interfering with GABA mechanisms, serotonin 5-HT1A receptors, mu-opioid receptors and alpha-adrenoreceptors. However, considering the limited predictability of existing animal models for efficacy in humans, positive proof of concept studies in humans are mandatory. Such studies are scarce and further investigations are needed.

Marriage, impairment, and acceptance in persons with multiple sclerosis

The purpose of this study was to investigate the relationship between marital status, marital concern, perceived impairment, health-promoting behaviors, and acceptance of disability using cross-sectional and longitudinal data from a sample of persons with multiple sclerosis (MS). We hypothesized that the quality and stability of the marital relationship would influence people's ability to accept their disability and protect from accumulation of impairment over time. Furthermore, men and women would receive dissimilar benefits from marriage. These hypotheses were considered with repeated measures analysis, Pearson correlations, and independent sample t tests of data obtained from a longitudinal study of persons with MS. The findings indicate that acceptance of disability and perceived impairment increase significantly over time for men and women. For men, being married was associated with a greater acceptance of disability and less perceived impairment. Men were more concerned than the women about how MS affected their sexual relationships.

Effects of TAK-802, a novel acetylcholinesterase inhibitor, on distension-induced rhythmic bladder contractions in rats and guinea pigs

In the present study, we investigated the effects of 8-[3-[1-[(3-fluorophenyl)methyl]-4-piperidinyl]-1-oxopropyl]-1,2,5,6-tetrahydro-4H-pyrrolo[3,2,1-ij]quinolin-4-one (TAK-802), a novel acetylcholinesterase inhibitor, on distension-induced rhythmic bladder contractions in urethane-anesthetized rats and guinea pigs. TAK-802 potently inhibited human-erythrocyte-derived acetylcholinesterase activity with an IC(50) value of 1.5 nM, which represented a potency 30 and 250 times greater than that of the two carbamate acetylcholinesterase inhibitors, neostigimine and distigmine, respectively. Unlike the carbamate acetylcholinesterase inhibitors, TAK-802 exhibits high selectivity for acetylcholinesterase inhibition over butyrylcholinesterase inhibition. In an assay conducted to measure the muscarinic and nicotinic actions, TAK-802 was found to exhibit higher selectivity for muscarinic actions over nicotinic actions in comparison to distigmine. Both TAK-802 and distigmine increased isovolumetric bladder contractions in rats and guinea pigs in a dose-dependent manner, with a minimum effective dose (MED) of 0.01 and 0.03 mg/kg i.v., respectively, in rats, and 0.01 and 0.1 mg/kg i.v., respectively, in guinea pigs. The effects of both the drugs were completely abolished by atropine. These results suggest that TAK-802 and other acetylcholinesterase inhibitors can effectively increase reflex bladder contractions by increasing the efficacy of acetylcholine released by nerve impulses. On the other hand, bethanechol, a muscarinic agonist, markedly changed the pattern of distension-induced bladder contractions when administered at the dose of 1 mg/kg i.v., and it did not necessarily augment well-coordinated bladder contractions. Thus, considering that it has some selectivity for muscarinic action, TAK-802 might be expected to be useful in the treatment of voiding dysfunction caused by impaired detrusor contractility.