Mechanisms of Pelvic Organ Cross-Talk: Impact of Urethral Ligation on the Inhibitory Rectovesical Reflex

Expectations about the management of sexual dysfunction in women with multiple sclerosis and association with clinical characteristics

BACKGROUND

Sexual dysfunction (SD) is common in women with multiple sclerosis (MS) and affects their quality of life.

OBJECTIVES

The primary aim is to assess their expectations concerning SD management. The secondary aim is to identify if expectations were associated with specific patient's characteristics.

METHODS

All women with MS who underwent a urodynamic assessment in a neuro-urology clinic and had a standardized assessment of SD expectations between June 2020 and November 2022 were retrospectively screened. Demographic data and assessment of bladder, bowel, and sexual dysfunctions with validated questionnaires were collected.

RESULTS

One hundred and sixty-seven patients were included in the study (mean age 47.9 ± 12.5 years). Expectations on SD information or management were reported by 112 (67.1%) patients. Interest in SD information and management was less frequent after menopause (56% vs 80%, p = 0.004), and in those with EDSS>6 (49% vs 74%, p = 0.03) and progressive type of MS (54% vs 71% p = 0.003). In multivariate analysis, the progressive type of MS was the only criterion related to a lack of interest (OR=2.9 IC95% [1.09; 7.72]).

CONCLUSIONS

Women with MS have high expectations on treatment and information about SD. A systematic screening of SD expectations should be encouraged.

Defining urge as an uncontrolled micturition explains pathogenesis, informs cure and helps solve the burgeoning OAB crisis

BACKGROUND

Parallel with the demographic ageing crisis, is a disabling overactive bladder (OAB) crisis (urgency/frequency/nocturia), 30% prevalence in older women, pathogenesis stated as unknown and, according to some learned societies, incurable.

HYPOTHESIS/AIMS

To review International Continence Society and Integral System paradigms to test our thesis that OAB per se is not a pathological condition, rather, a prematurely activated uncontrolled micturition; pathogenesis being anatomical damage in a nonlinear feedback control system comprising cortical and peripheral (muscle/ligament) components.

METHODS

We examined studies from basic science, anatomy, urodynamics, ultrasonic and video xrays, ligament repairs, from which we created a nonlinear binary model of bladder function. We applied a Chaos Theory feedback equation, Xnext  = Xc(1 - X) to test our hypothesis against existing concepts and hypotheses for OAB pathogenesis.

RESULTS

The bladder has ONLY two modes, EITHER closed OR open (micturition). Closure is reflexly controlled cortically and peripherally: muscles contracting against ligaments stretch the vagina to suppress afferent signals to micturate from urothelial stretch receptors. "OAB" can be caused by anatomical damage anywhere in the model, by childbirth or age-weakened ligaments, which can be repaired to cure all three OAB symptoms. Urodynamic "DO" graphs are interpreted anatomically and by the feedback equation.

CONCLUSION

OAB is in crisis. Our thesis of OAB as an uncontrolled micturition from anatomical defects in the bladder control system provides fresh directions for further development of new treatments, nonsurgical and surgical, to help break the crisis and bring hope and cure to 600 million women sufferers.

An anatomical pathogenesis of lower urinary tract definitions from the 2002 ICS report symptoms, conditions, syndromes, urodynamics

AIM

To present an anatomical pathogenesis parallel with the 2002 International Continence Society Lower Urinary Tract (LUTS) definitions standardization Report 2002.

METHODS

Each LUTS section is discussed using the same numbers as the Report.

RESULTS

Normal function Bladder control is binary, with two reflexes alternating, either closure (dominant) or open (micturition), with the same cortical and peripheral components: three directional muscle forces contracting against pubourethral (PUL) and uterosacral (USL) ligaments for closure, two against uterosacral ligaments for micturition. Dysfunction OAB symptoms reflect a prematurely activated micturition; PUL/USL weakness prevents muscle forces from controlling afferent urothelial emptying signals. Stress urinary incontinence is a consequence of weak PULs allowing posterior muscle forces to open the urethra during effort. Lax USLs weaken contractile force of the posterior urethral opening vectors, so detrusor has to contract against an unopened urethra. This is experienced as "obstructive micturition."

CONCLUSIONS

Anatomical analysis indicates the ICS definitions are fundamentally sound, except for "OAB" which implies detrusor causation. Minor changes, OAB to "overactivated" bladder allow causation outside of bladder. This construct supports OAB and its component symptoms as a syndrome, as intuited by the Committee, (albeit as a prematurely activated micturition), retains the acronym, explains OAB cure by ligament repair, and incontinence pathogenesis from two post-2002 syndromes which need an addition to the definitions, Posterior Fornix Syndrome (of which OAB is a component) and Tethered Vagina Syndrome, which is the basis for skin-grafting cure of the 30%-50% of women who continue leaking urine massively after successful obstetric fistula closure.

Relationship between desire to void and bladder capacity and rectal sensory function in patients with multiple sclerosis and anorectal disorders

AIMS

The primary aim of this study was to assess the relationship between a strong desire to void (SDV) and rectal sensory function in patients with multiple sclerosis (PwMS) and anorectal disorders. The secondary aim was to identify clinical, urodynamic or manometric factors associated with greater rectal sensory function impairment in this population.

METHODS

Thirty PwMS (mean age 49.2 ± 10.9 years) with anorectal disorders (constipation and/or fecal incontinence) participated in this observational study. Rectal sensory parameters during anorectal manometry were recorded at a strong desire to void and after urination (PV, post-void). The primary outcome was the desire to defecate volume. Secondary outcomes were first perception and maximum tolerated threshold volumes, presence and modulation of recto-anal inhibitory reflex.

RESULTS

The mean desire to defecate volume was 125 ± 59 mL at SDV and 104 ± 64 mL at PV (P < .001). The mean maximum tolerated volume was 167 ± 61 mL at SDV vs 141 ± 64 mL after urination (P = .01). The other parameters were not different between SVD and PV conditions. No predictive factors for greater impairment of rectal sensory function were identified.

CONCLUSION

This study suggests a relationship between bladder sensation and thus bladder capacity, and rectal sensory function in PwMS and with anorectal disorders.

Medullary raphe nuclei activate the lumbosacral defecation center through the descending serotonergic pathway to regulate colorectal motility in rats

Colorectal motility is regulated by two defecation centers located in the brain and spinal cord. In previous studies, we have shown that administration of serotonin (5-HT) in the lumbosacral spinal cord causes enhancement of colorectal motility. Because spinal 5-HT is derived from neurons of the medullary raphe nuclei, including the raphe magnus, raphe obscurus, and raphe pallidus, we examined whether stimulation of the medullary raphe nuclei enhances colorectal motility via the lumbosacral defecation center. Colorectal pressure was recorded with a balloon in vivo in anesthetized rats. Electrical stimulation of the medullary raphe nuclei failed to enhance colorectal motility. Because GABAergic neurons can be simultaneously activated by the raphe stimulation and released GABA masks accelerating actions of the raphe nuclei on the lumbosacral defecation center, a GABA_A receptor antagonist was preinjected intrathecally to manifest excitatory responses. When spinal GABA_A receptors were blocked by the antagonist, electrical stimulation of the medullary raphe nuclei increased colorectal contractions. This effect of the raphe nuclei was inhibited by intrathecal injection of 5-hydroxytryptamine type 2 (5-HT₂) and type 3 (5-HT₃) receptor antagonists. In addition, injection of a selective 5-HT reuptake inhibitor in the lumbosacral spinal cord augmented the raphe stimulation-induced enhancement of colorectal motility. Transection of the pelvic nerves, but not transection of the colonic nerves, prevented the effect of the raphe nuclei on colorectal motility. These results demonstrate that activation of the medullary raphe nuclei causes augmented contractions of the colorectum via 5-HT₂ and 5-HT₃ receptors in the lumbosacral defecation center. NEW & NOTEWORTHY We have shown that electrical stimulation of the medullary raphe nuclei causes augmented contractions of the colorectum via pelvic nerves in rats. The effect of the medullary raphe nuclei on colorectal motility is exerted through activation of 5-hydroxytryptamine type 2 and type 3 receptors in the lumbosacral defecation center. The descending serotoninergic raphespinal tract represents new potential therapeutic targets against colorectal dysmotility such as irritable bowel syndrome.

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.