Approach to the male patient with lower urinary tract dysfunction

What is the clinical meaning of a negative bulbocavernosus reflex in spinal cord injury patients?

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To highlight some issues about the clinical meaning of a negative bulbocavernosus reflex (BCR) in spinal cord injury (SCI) patients.

SETTINGS

Research group University Antwerp Belgium.

METHODS

The study included 170 patients in whom the BCR was examined at a mean of 7 years post SCI. Changes over time were explored in a subset of patients.

RESULTS

BCR was negative in 45%. There was no influence of age and gender, nor could a relation be found with the American Spinal Injury Association Impairment Scale score. The anal sphincter reflex (ASR) was positive in 13% of patients with negative BCR. With a mean interval of 45 weeks, BCR changed in 32% of a subset of 44 patients (14 became positive, 3 negative), while the neurological condition did not change and no treatments had been given that could influence the outcome. The data show that a negative BCR may not only be due to a disrupted reflex nervous pathway (which in some patients is different from that of ASR), but may also be caused by a difficulty to provoke the reflex.

CONCLUSION

A negative BCR test indicates interruption of the reflex neurologic pathways, but can also depend on the ease to elicit the reflex. By also doing ASR, this dilemma can be partly solved.

Testing sensation of gently squeezing the testes has diagnostic value in spinal cord injury men

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Determine the diagnostic value of testing the sensation of squeezing the testes.

SETTING

Research group run by the University of Antwerp.

METHODS

During the clinical examination, it was evaluated if male spinal cord injury (SCI) patients felt gentle squeezing of the testes. The outcome was related to the type of SCI, to the sensations of the light touch of the dermatomes of the perineum, of bladder filling, of overactive detrusor (DOA) contractions during urodynamics, and of electrosensation elicited in different parts of the lower urinary tract. The neurological pathways elicited by these tests were compared.

RESULTS

Seventy-four patients were included, mean age 46 ± 17 years, a number of weeks post SCI 318 ± 586. Sensation in the testes was present in 72.2%. In patients with AIS A, the sensation was found positive in 41%, while all with AIS B-D felt the sensation. Testes sensation was strongly correlated with the sensation of touch of the perineum and with the filling sensation during cystometry, proving a dorsal column pathway. The sensation of DOA contractions and electrosensation in the bladder, bladder neck/proximal, and distal urethra were not significantly related to the outcome of the testicular examination, showing that anterior and lateral spinothalamic pathways were not involved CONCLUSIONS: Our data show that sensation from gently squeezing the testes informs about the dorsal column from spinal cord level T10-L2 upwards. The test can help refine the neurologic diagnosis after SCI. We advocate to include this easy-to-do test in the neuro-urologic clinical examination.

The management of neurogenic lower urinary tract dysfunction after spinal cord injury

The management of patients with neurogenic bladder has changed substantially over the past decades. Obtaining balanced lower urinary tract function has become possible in most patients, although, urological complications remain among the most serious complications these patients are likely to have and, even today, these can have a negative effect on quality of life. To this extent, patients with spinal cord injury (SCI) are likely to develop neurogenic bladder, and data are available on most aspects of neurogenic bladder in these patients. Data on physiology and pathophysiology form the basis of our understanding of patients' symptoms, and also provide a basis for the management of these patients. The use of conservative, and/or more invasive treatment measures, their complications and measures to prevent these complications, are all important clinical aspects that merit discussion. Considerable progress has been made in the urological management of patients with SCI over the past decades, but opportunities remain to make diagnosis more accurate and therapy more successful.