Neurophysiology in neurourology

Reducing CAUTI in patients with acute urinary retention in the critical care setting: A pilot study with electronic medical record analytics

BACKGROUND

This study implemented and evaluated an algorithm protocol for management of indwelling urinary catheters (IUCs) among patients treated for acute urinary retention (AUR) in an intensive care unit. The algorithm protocol (1) instituted in and out catheterization before placing an IUC for retention; (2) encouraged more consistent use of medications for AUR; and (3) provided for prompt removal of IUCs placed for AUR.

METHODS

An uncontrolled pre- and post-test intervention approach was used to assess the impact of the algorithm on the treatment of AUR. Bivariate and multivariate analyses assessed data collected using 2 approaches: (1) electronic extracts from the electronic medical record (EMR) vs (2) manual chart reviews.

RESULTS

Findings suggest that the intervention decreased indwelling IUC days by 1.93 average days and increased medication prescription rates. An EMR extract identified fewer catheters per patient pre-intervention than a manual chart review, but otherwise the differences observed in the EMR extract and manual chart review were insignificant.

CONCLUSIONS

Implications for practitioners and administrators are that the algorithm protocol may reduce CAUTI risk and - provided consistent EMR documentation - EMR extracts may represent an efficient and effective approach for monitoring data when spreading the intervention.

The effect of amino acids on the bladder cycle: a concise review

The human bladder maintains a cycle of filling, storing, and micturating throughout an individual's lifespan. The cycle relies on the ability of the bladder to expand without increasing the intravesical pressure, which is only possible with the controlled relaxation of well-complaint muscles and the congruously organized construction of the bladder wall. A competent bladder outlet, which functions in a synchronous fashion with the bladder, is also necessary for this cycle to be completed successfully without deterioration. In this paper, we aimed to review the contemporary physiological findings on bladder physiology and examine the effects of amino acids on clinical conditions affecting the bladder, with special emphasis on the available therapeutic evidence and possible future roles of the amino acids in the treatment of the bladder-related disorders.

Occurrence and Severity of Catheter-Related Bladder Discomfort of General Anesthesia Plus Epidural Anesthesia vs. General Anesthesia in Abdominal Operation With Urinary Catheterization: A Randomized, Controlled Study

Background: This randomized, controlled study aimed to investigate the effect of general anesthesia plus epidural anesthesia on catheter-related bladder discomfort (CRBD) in patients who underwent abdominal operation with urinary catheterization.

Methods: A total of 150 patients scheduled for abdominal operation under anesthesia with urinary catheterization were randomized to receive general anesthesia plus epidural anesthesia (N = 74, GA + EA group) or general anesthesia (N = 76, GA group). The occurrence and severity of CRBD, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded at 0 hour (h), 0.5, 1, and 3 h after tracheal extubation. Besides, postoperative adverse events were assessed.

Results: The occurrence and severity of CRBD at 0, 0.5, 1, and 3 h were all reduced in GA + EA group compared to GA group (all P < 0.05). Meanwhile, subgroup analyses showed that the reduction of occurrence and severity of CRBD in GA + EA group compared to GA group was more obvious in male patients and patients ≥50 years. Besides, SBP at 0, 0.5, 1, and 3 h, as well as DBP at 0, 0.5, and 3 h were all decreased in GA + EA group compared to GA group (all P < 0.05), while HR was increased at 0 h in GA + EA group compared to GA group (P = 0.034). Moreover, the occurrence of pain, severity of pain and occurrence of vomiting were similar between GA + EA group and GA group (all P > 0.05).

Conclusion: General anesthesia plus epidural anesthesia decreases CRBD occurrence and severity with tolerable safety compared with general anesthesia in patients who undergo abdominal operation with urinary catheterization.

Relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in patients with obstructed defecation

Background

Obstructed defecation is a common pelvic floor medical problem among adult population. Pelvic floor disorders were reported to be associated with sexual dysfunction including erectile dysfunction among male patients. The aim was to determine the relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in male patients with obstructed defecation.

Methods

This cross-sectional study included 65 married male patients with obstructed defecation and a control group consisted of 15 apparently healthy married males. Assessment of obstructed defecation severity was done by using modified obstructed defecation score, time of toileting and Patient Assessment of Constipation-Quality of Life questionnaire. Assessment of erectile functions was done using erectile function domain of International Index of Erectile Function questionnaire and Erectile Dysfunction-Effect on Quality of Life Questionnaire. Anal manometry and dynamic pelvis magnetic resonance imaging were done. Electrophysiological studies included pudendal nerve motor conduction study and needle electromyography of external anal sphincter, puborectalis and bulbocavernosus muscles.

Results

There were 32 patients (49.2%) who had erectile dysfunction. The maximum straining anal pressure was significantly higher among patients with erectile dysfunction. Pudendal nerve terminal motor latency was significantly delayed and the percentage of bilateral pudendal neuropathy was significantly higher among patients with erectile dysfunction. The percentage of electromyography evidence of denervation with chronic reinnervation in the external anal sphincter and bulbocavernosus muscles were significantly higher among patients with erectile dysfunction. Regression analysis detected three co-variables to be associated with significantly increasing the likelihood of development of erectile dysfunction. These were maximum straining anal pressure (odd ratio = 1.122), right pudendal nerve terminal motor latency (odd ratio = 3.755) and left pudendal nerve terminal motor latency (odd ratio = 3.770).

Conclusions

Erectile dysfunction is prevalent among patients with obstructed defecation. It is associated with characteristic pelvic floor electrophysiological abnormalities. Pelvic floor neurophysiological changes vary from minimal to severe neuromuscular abnormalities that usually accompanying erectile dysfunction. Pudendal neuropathy and increased maximum straining anal pressure are essential risk factors for increasing the likelihood of development of erectile dysfunction in patients with obstructed defecation.

The sacral exam-what is needed to best care for our patients?

Sacral reflexes are important to allow the SCI practitioner to gain information about the state of the sacral spinal cord segments. The presence of the bulbocavernosus and/or the anal wink reflex indicate an intact spinal reflex arc and reflex conal autonomic function (as part of the upper motor neuron syndrome); their absence defines a lower motor neuron syndrome. The assessment of sacral reflexes helps predict the type of bladder, bowel and sexual functions and the related therapeutic interventions. We suggest adding the sacral component of the International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) to the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) examination so there can be a detailed description of these important functions. As an alternative, the performance of sacral reflexes should be routinely required as part of the neurologic examination after SCI. Whether the sacral motor neuron system is classified as upper or lower motor neuron injury is also quite useful and as such should be present in the ISCNSCI.

Anal reflex versus bulbocavernosus reflex in evaluation of patients with spinal cord injury

The examination of sacral reflexes provides an important method to differentiate an upper motor neuron vs lower motor neuron spinal cord injury (SCI). Two common sacral mediated reflexes used as part of the neurological assessment include the bulbocavernosus reflex (BCR) and anal reflex. As the clinical information from these tests are similar, we suggest that the anal reflex provides a better first option as a non-invasive clinical assessment of sacral reflex status in clinical practice in SCI as the testing for the anal reflex is less intrusive and already being performed as part of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by pinprick stimulation of the S4-5 dermatome.

Neurophysiologic study in idiopathic overactive bladder

AIM

Idiopathic overactive bladder (OAB) is a prevalent, mystifying disorder with a questionable neurogenic background. We aimed to investigate the possible subtle neuropathic affection underlying its pathogenesis.

METHODS

A cross-sectional cut off study was carried out on a series of 38 females with idiopathic OAB and 22 healthy matched female volunteers. The following was performed: symptom score questionnaire, determination of pudendal nerve terminal motor latency (PNTML), sacral reflexes' latencies, pudendal somatosensory evoked potentials, and needle electromyography of the external anal and urethral sphincters.

RESULTS

A highly significant prolongation of PNTMLs and sacral reflexes latencies among the patients group was detected (P ≥ 0.001). Pudendal somatosensory evoked potentials showed non- significance among the two studied groups (P ≥ 0.05). External anal sphincter neuropathic affection was detected in 27 patients (71%) and external urethral sphincter neuropathic affection was detected in 30 patients (78.9%). The clitoral anal reflex showed the highest sensitivity and specificity among the neurophysiologic tests used in assessing the neuropathic affection (86.7 and 83%, respectively), followed by PNTML (83.3 and 80%, respectively).

CONCLUSION

Pudendal neuropathy is the dominating possible attributing factor in the pathogenesis underlying idiopathic OAB. An integrated clinical, urodynamic, and electro-physiological assessment is recommended for evaluation of any overactive bladder patients.

Anal sphincter dysfunction in multiple sclerosis: an observation manometric study

Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient.

RESULTS

Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively).

CONCLUSIONS

The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.

Evidence-Based Continence Care: An Integrative Review

PURPOSE

The purpose of this integrative review is to identify the best nurse-managed continence care strategies among rehabilitation patients from the current body of evidence.

DESIGN

The newly designed 2015 Competency Model for Professional Rehabilitation Nursing serves as a conceptual framework to categorize evidence-based recommendations for continence care into the four domains of the model.

METHODS

A search of the evidence was completed in December 2015. Literature reviewed was limited to articles published from 2005-2015 in the English language. Search priority was given to systematic reviews and randomized controlled trials.

FINDINGS

Nurse-led interventions include evidence-based clinical assessments with use of validated instruments following step-wise algorithms derived from clinical practice guidelines. The interprofessional team emphasizes role-based continence interventions with shared work to reach goals. Leadership recommendations call for administrative support and allocation of resources for continence care and also empower select bedside nurses to become continence champions. Finally, nurse-patient education and caregiver training target the promotion of successful living. System-based continence recommendations are identified to include rehab-oriented electronic documentation systems, written continence policies and procedures, and ongoing nursing education emphasizing accountability to high performance standards.

CONCLUSIONS

Rehabilitation nurses are the team leaders in promoting continence in the rehabilitation setting. They are the cultivators of hope and foster resilience among patients to move forward despite acute or chronic illness and disability. This article is intended to support rehabilitation nurses in their review of clinical evidence in effort to move toward a more uniform approach to bowel and bladder management.

CLINICAL RELEVANCE

This review equips rehabilitation nurses who seek to improve their practice by identifying the best evidence-based approaches to continence care.

Idiopathic giant atonic bladder (6000 mL in volume) present for 15 years with no urinary symptoms

Urinary retention is common in patients with neurologic disorders. We present a case of asymptomatic idiopathic giant bladder from which 6000 mL urine was drained. This is the largest volume of bladder that we found in the literature.

Cardiovascular and urological dysfunction in spinal cord injury

OBJECTIVE

A spinal cord injury (SCI) above the sixth thoracic vertebra interrupts the supraspinal control of the sympathetic nervous system causing an imbalance between the sympathetic and the parasympathetic nervous system. This article focuses on the symptoms, treatment and examination of autonomic disturbances of the cardiovascular and the urinary system after a SCI.

METHODS

A non-systematic literature search in the PubMed database.

RESULTS

Frequent complications in the acute phase of cervical and high thoracic SCI are bradyarrhythmias, hypotension, hypothermia/hyperthermia, increased neurogenic shock, vagovagal reflex, supraventricular/ventricular ectopic beats, vasodilatation and congestion. Serious complications in the chronic phase of SCI are orthostatic hypotension, impaired cardiovascular reflexes, autonomic dysreflexia (AD), reduced sensation of cardiac pain, loss of reflex cardiac acceleration, quadriplegic cardiac atrophy due to loss of left ventricular mass and pseudo-myocardial infarction. AD is associated with a sudden, uncontrolled sympathetic response, triggered by stimuli below the injury. It may cause mild symptoms like skin rash or slight headache, but also severe hypertension, cerebral haemorrhage and death. Early recognition and prompt treatment are important. Urinary autonomic dysfunctions include hyperreflexia or areflexia of detrusor and/or sphincter of the bladder.

CONCLUSIONS

Patients with SCI have a high risk of cardiovascular complications, AD and urinary autonomic dysfunction both in the acute phase and later, affecting their prognosis and quality of life. Knowledge of cardiovascular and urological complications after SCI is important for proper diagnosis and treatment.

A review of botulinum toxin use for chronic pelvic pain syndrome

The inability of urologists to consistently and effectively treat men with chronic pelvic pain syndrome (CPPS), also known as chronic abacterial prostatitis, is a source of great frustration. Botulinum toxin (BTX), a potent neurotoxin, can act on most of the peripheral nerves of the pelvis through a variety of mechanisms. BTX injection therapy for CPPS treatment has shown modest improvements. BTX is ideal for integration into a multimodal treatment plan, which may help achieve pain relief in men with chronic pelvic pain.