Management of detrusor-external sphincter dyssynergia

Conservative Bladder Management and Medical Treatment in Chronic Spinal Cord Injury Patients

To review the available data on non-surgical management for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI) and provide the most updated knowledge for readers. We categorized the bladder management approaches into storage and voiding dysfunction separately; both are minimally invasive, safe, and efficacious procedures. The main goals for NLUTD management are to achieve urinary continence; improve quality of life; prevent urinary tract infections and, last but not least, preserve upper urinary tract function. Annual renal sonography workups and regular video urodynamics examinations are crucial for early detection and further urological management. Despite the extensive data on NLUTD, there are still relatively few novel publications and there is a lack of high-quality evidence. There is a paucity of new minimally invasive and prolonged efficacy treatments for NLUTD, and a partnership between urologists, nephrologists and physiatrists is required to promote and ensure the health of SCI patients in the future.

Molecular Mechanism Operating in Animal Models of Neurogenic Detrusor Overactivity: A Systematic Review Focusing on Bladder Dysfunction of Neurogenic Origin

Neurogenic detrusor overactivity (NDO) is a severe lower urinary tract disorder, characterized by urinary urgency, retention, and incontinence, as a result of a neurologic lesion that results in damage in neuronal pathways controlling micturition. The purpose of this review is to provide a comprehensive framework of the currently used animal models for the investigation of this disorder, focusing on the molecular mechanisms of NDO. An electronic search was performed with PubMed and Scopus for literature describing animal models of NDO used in the last 10 years. The search retrieved 648 articles, of which reviews and non-original articles were excluded. After careful selection, 51 studies were included for analysis. Spinal cord injury (SCI) was the most frequently used model to study NDO, followed by animal models of neurodegenerative disorders, meningomyelocele, and stroke. Rats were the most commonly used animal, particularly females. Most studies evaluated bladder function through urodynamic methods, with awake cystometry being particularly preferred. Several molecular mechanisms have been identified, including changes in inflammatory processes, regulation of cell survival, and neuronal receptors. In the NDO bladder, inflammatory markers, apoptosis-related factors, and ischemia- and fibrosis-related molecules were found to be upregulated. Purinergic, cholinergic, and adrenergic receptors were downregulated, as most neuronal markers. In neuronal tissue, neurotrophic factors, apoptosis-related factors, and ischemia-associated molecules are increased, as well as markers of microglial and astrocytes at lesion sites. Animal models of NDO have been crucial for understanding the pathophysiology of lower urinary tract (LUT) dysfunction. Despite the heterogeneity of animal models for NDO onset, most studies rely on traumatic SCI models rather than other NDO-driven pathologies, which may result in some issues when translating pre-clinical observations to clinical settings other than SCI.

Real-World Data Regarding Satisfaction to Botulinum Toxin A Injection into the Urethral Sphincter and Further Bladder Management for Voiding Dysfunction among Patients with Spinal Cord Injury and Voiding Dysfunction

Purpose: This study aimed to investigate improvement in voiding condition after the initial botulinum toxin A (BoNT-A) injection into the urethral sphincter among patients with chronic spinal cord injury (SCI) and voiding dysfunction. Moreover, subsequent surgical procedures and bladder management were evaluated. Materials and Methods: From 2011 to 2020, 118 patients with SCI and dysuria who wanted to void spontaneously received their first BoNT-A injection at a dose of 100 U into the urethral sphincter. Improvement in voiding and bladder conditions after BoNT-A treatment were assessed. Next, patients were encouraged to continually receive BoNT-A injections into the urethral sphincter, convert to other bladder managements, or undergo surgery. After undergoing bladder management and surgical procedures, the patients were requested to report improvement in voiding condition and overall satisfaction to bladder conditions. Then, data were compared. Results: In total, 94 male and 24 female participants were included in this analysis. Among them, 51 presented with cervical, 43 with thoracic, and 24 with lumbosacral SCI. After BoNT-A injections into the urethral sphincter, 71 (60.2%) patients, including 18 (15.3%) with excellent, and 53 (44.9%) with moderate improvement, had significant improvement in voiding condition. Patients with cervical SCI (66.6%), detrusor overactivity and detrusor sphincter dyssynergia (72.0%), partial hand function (80.0%), and incomplete SCI (68.4%) had a better improvement rate than the other subgroups. Only 42 (35.6%) patients continually received treatment with BoNT-A injections into the urethral sphincter. Meanwhile, more than 60% of patients who converted their treatment to augmentation enterocystoplasty (n = 5), bladder outlet surgery (n = 25), BoNT-A injections into the detrusor muscle (n = 20), and medical treatment (n = 55) had moderate and marked improvement in voiding dysfunction and overall satisfaction. Discussion: Although BoNT-A injections into the urethral sphincter could improve voiding condition, only patients with SCI who presented with voiding dysfunction were commonly satisfied. Those whose treatments were converted to other bladder managements, which can promote urinary continence, or to surgical procedures, which can facilitate spontaneous voiding, had favorable treatment outcomes.

Research advances of biomaterials-based microenvironment-regulation therapies for repair and regeneration of spinal cord injury

Traumatic spinal cord injury (SCI) usually results in restricted behaviour recovery and even life-changing paralysis, accompanied with numerous complications. Pathologically, the initial injuries trigger a series of secondary injuries, leading to an expansion of lesion site, a mass of neuron loss, and eventual failure of endogenous axon regeneration. As the advances rapidly spring up in regenerative medicine and tissue engineering biomaterials, regulation of these secondary injuries becomes possible, shedding a light on normal functional restoration. The successful tissue regeneration lies in proper regulation of the inflammatory microenvironment, including the inflammatory immune cells and inflammatory factors that lead to oxidative stress, inhibitory glial scar and neuroexcitatory toxicity. Specifically, the approaches based on microenvironment-regulating biomaterials have shown great promise in the repair and regeneration of SCI. In this review, the pathological inflammatory microenvironments of SCI are discussed, followed by the introduction of microenvironment-regulating biomaterials in terms of their impressive therapeutic effect in attenuation of secondary inflammation and promotion of axon regrowth. With the emphasis on regulating secondary events, the biomaterials for SCI treatment will become promising for clinical applications.

Tradução para a língua portuguesa do artigo original em inglês “ The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction”

Introdução

No desenvolvimento da terminologia do trato urinário inferior, devido à sua crescente complexidade, a terminologia para os sintomas e a disfunção do trato urinário inferior masculino e assoalho pélvico precisa ser atualizada, utilizando abordagem específica masculina e por meio de um relatório de consenso clinicamente embasado.

Métodos

Este relatório combina a contribuição de membros do Standardisation Committee da International Continence Society em um Grupo de Trabalho com especialistas reconhecidos no campo, assistido por muitos julgadores externos. Categorias clínicas centrais apropriadas e uma subclassificação foram desenvolvidas para fornecer uma codificação numérica para cada definição. Um extenso processo de 22 rodadas de revisão interna e externa foi desenvolvido para examinar exaustivamente cada definição, com tomada de decisão por opinião coletiva (consenso).

Resultados

Um relatório de terminologia para os sintomas e a disfunção do trato urinário inferior e do assoalho pélvico foi desenvolvido, abrangendo cerca de 390 definições/descritores separados. É clinicamente embasado nos diagnósticos mais comuns definidos. A clareza e a facilidade de uso foram os principais objetivos para torná-lo interpretável por profissionais e estagiários em todos os diferentes grupos de especialidades envolvidos na disfunção do trato urinário inferior e do assoalho pélvico masculino. Imagens específicas para homens (ultrassonografia, radiologia, tomografia computadorizada e ressonância magnética) foram um adicional importante, enquanto figuras apropriadas foram incluídas para complementar e ajudar a esclarecer o texto.

Conclusões

Um relatório de terminologia com base em consenso para sintomas e disfunção do trato urinário inferior e do assoalho pélvico masculino foi produzido visando ser um auxílio significativo para a prática clínica e um estímulo para a pesquisa.

[External sphincterotomy in neurological patients with detrusor sphincter dyssynergia: Short and mid-term results]

BACKGROUND

To evaluate in the short and mid-term the success of external sphincterotomy (ES) in neurological patients with detrusor sphincter dyssynergia (DSD).

METHODS

Retrospective, monocentric study, conducted in 51 patients who had a first ES between January 2003 and June 2018, with at least two years of follow-up. The success of ES was defined by maintenance of reflex voiding mode at the end of follow-up. Secondary outcomes were early postoperative complications, rate of revision, functional impact, urodynamic follow-up and upper urinary tract impact.

RESULTS

The median age was 50.6 years and the median follow-up was 4.6 years. The success rate was 80% (n=41). Ten patients had to change their voiding mode. For 5 patients, it was related to secondary detrusor low contractility. A second ES was required for 39% of patients. At the end of follow-up, there was a significant improvement in Autonomic Dysreflexia (AD) (26 vs 7 patients, P<0.001), urinary tract infections (UTI) (31 vs 15 patients, P<0.001) and a significant decrease in post-voiding residuals (200 vs 50mL, P<0.001).

CONCLUSION

ES allowed to maintain reflex voiding in 80% of our patients. It significantly improves AD and UTI despite a high rate of re-operation (39%). A long-term follow-up is mandatory in order not to ignore a recurrence of bladder outlet obstruction and/or decrease in detrusor contractility, which may justify a re-operation or an alternative bladder management.

LEVEL OF EVIDENCE

III.

Biomarkers in Spinal Cord Injury: Prognostic Insights and Future Potentials

Spinal Cord Injury (SCI) is a major challenge in Neurotrauma research. Complex pathophysiological processes take place immediately after the injury and later on as the chronic injury develops. Moreover, SCI is usually accompanied by traumatic injuries because the most common modality of injury is road traffic accidents and falls. Patients develop significant permanent neurological deficits that depend on the extent and the location of the injury itself and in time they develop further neurological and body changes that may risk their mere survival. In our review, we explored the recent updates with regards to SCI biomarkers. We observed two methods that may lead to the appearance of biomarkers for SCI. First, during the first few weeks following the injury the Blood Spinal Cord Barrier (BSCB) disruption that releases several neurologic structure components from the injured tissue. These components find their way to Cerebrospinal Fluid (CSF) and the systemic circulation. Also, as the injury develops several components of the pathological process are expressed or released such as in neuroinflammation, apoptosis, reactive oxygen species, and excitotoxicity sequences. Therefore, there is a growing interest in examining any correlations between these components and the degrees or the outcomes of the injury. Additionally, some of the candidate biomarkers are theorized to track the progressive changes of SCI which offers an insight on the patients' prognoses, potential-treatments-outcomes assessment, and monitoring the progression of the complications of chronic SCI such as Pressure Ulcers and urinary dysfunction. An extensive literature review was performed covering literature, published in English, until February 2018 using the Medline/PubMed database. Experimental and human studies were included and titles, PMID, publication year, authors, biomarkers studies, the method of validation, relationship to SCI pathophysiology, and concluded correlation were reported. Potential SCI biomarkers need further validation using clinical studies. The selection of the appropriate biomarker group should be made based on the stage of the injuries, the accompanying trauma and with regards to any surgical, or medical interference that might have been done. Additionally, we suggest testing multiple biomarkers related to the several pathological changes coinciding to offer a more precise prediction of the outcome.

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction

INTRODUCTION

In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text.

CONCLUSIONS

A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

[External sphincterotomy in neurological patients: A monocentric experience]

AIM

The aim of this study was to assess the feasibility, efficacy and tolerance of Greenlight™ and Holmium sphincterotomy for treating detrusor-sphincter dyssynergia.

METHODS

All men treated with this two techniques between may 2012 and june 2015 were analyzed. Preoperative evaluation included kidney ultrasound scan, urodynamic, retrograde and voiding urethrocystography. Postoperative assessment was composed of a post-void residual volume measurement when the urethral catheter was removed and 1 year after the procedure, a retrograde and voiding urethrocystography at 3 months and telephonic Likert scale questionnaire.

RESULTS

Twelve patients were operated with Greenlight™ and 12 with Holmium. Eleven had a memocath urethral stent preoperatively. Post-void residual volume median for both techniques was 285 cc preoperatively vs 137.5 cc postoperatively (P<0.001). Likert scale global satisfaction was 75%. Five stenosis (20.8%) were observed within a median of 4 months.

CONCLUSION

Greenligth™ and Holmium procedures are efficient techniques with low morbidity. However, superiority toward monopolar incision remains to be demonstrated through complementary studies.

LEVEL OF EVIDENCE

4.

Anatomy and Physiology of the Urinary Tract: Relation to Host Defense and Microbial Infection

The urinary tract exits to a body surface area that is densely populated by a wide range of microbes. Yet, under most normal circumstances, it is typically considered sterile, i.e., devoid of microbes, a stark contrast to the gastrointestinal and upper respiratory tracts where many commensal and pathogenic microbes call home. Not surprisingly, infection of the urinary tract over a healthy person's lifetime is relatively infrequent, occurring once or twice or not at all for most people. For those who do experience an initial infection, the great majority (70% to 80%) thankfully do not go on to suffer from multiple episodes. This is a far cry from the upper respiratory tract infections, which can afflict an otherwise healthy individual countless times. The fact that urinary tract infections are hard to elicit in experimental animals except with inoculum 3-5 orders of magnitude greater than the colony counts that define an acute urinary infection in humans (105 cfu/ml), also speaks to the robustness of the urinary tract defense. How can the urinary tract be so effective in fending off harmful microbes despite its orifice in a close vicinity to that of the microbe-laden gastrointestinal tract? While a complete picture is still evolving, the general consensus is that the anatomical and physiological integrity of the urinary tract is of paramount importance in maintaining a healthy urinary tract. When this integrity is breached, however, the urinary tract can be at a heightened risk or even recurrent episodes of microbial infections. In fact, recurrent urinary tract infections are a significant cause of morbidity and time lost from work and a major challenge to manage clinically. Additionally, infections of the upper urinary tract often require hospitalization and prolonged antibiotic therapy. In this chapter, we provide an overview of the basic anatomy and physiology of the urinary tract with an emphasis on their specific roles in host defense. We also highlight the important structural and functional abnormalities that predispose the urinary tract to microbial infections.

Biomarkers of spinal cord injury and ensuing bladder dysfunction

During the acute phase of SCI, the extension and residual neurological deficits that will persist after the waning of the spinal shock period are difficult to estimate on clinical grounds. Therefore, objective biomarkers able to estimate the extension of the lesion and the degree of neurological recovery are of great importance. Research has been focused on the detection of structural neuronal and glial proteins that leak from damaged cells, inflammatory proteins recruited to remove necrotic debris and more accurate neuroimaging methods that are able to discriminate the extension and functional consequences of the SCI. Urinary biomarkers are also being investigated to estimate functional changes that typically affect bladder function following SCI which can endanger patient's life in the long run. Future studies are needed to precisely characterize the composition and function of the glial scar that appears in the area of SCI and repeals axonal growth, therefore preventing axonal rewiring.

Therapeutic outcome and quality of life between urethral and detrusor botulinum toxin treatment for patients with spinal cord lesions and detrusor sphincter dyssynergia

AIMS

Patients with spinal cord lesions and detrusor sphincter dyssynergia (DSD) may be treated with urethral sphincter botulinum toxin A (BoNT-A) injection for difficult urination or detrusor BoNT-A injection for incontinence. Although objective data showed improvement, patients might not be satisfied with the result especially in quality of life (QOL) issue. This study investigated the therapeutic results and QOL and patients' satisfaction to these two treatments.

PATIENTS AND METHODS

Patients with spinal cord lesion and DSD were treated with urethral sphincter injection of 100 U of BoNT-A for main symptoms of difficult urination and detrusor injection of 200 U of BoNT-A for main symptom of incontinence. The urodynamic parameters, QOL scores using UDI-6 and IIIQ-7 and general satisfaction were compared between two groups.

RESULTS

The overall satisfactory result was perceived in 60.6% and 77.3% in patients who received urethral and detrusor BoNT-A injection, respectively. Urodynamic parameters showed significant improvement in both groups. Urethral injection group had improvement in IIQ-7, but not in UDI-6 scores whereas detrusor injection group had improvement in all scores. The improvement of UDI-6 and IIQ-7 was significantly greater in detrusor than urethral injection group. Increase in incontinence grade was the major cause of dissatisfaction in urethral injection group, whereas increase in difficult urination and needing catheterisation were the main dissatisfaction causes in detrusor injection group.

CONCLUSION

There was discrepancy between the objective urodynamic results and patient satisfaction in treatment of DSD by BoNT-A injection. Patients with DSD and treated with detrusor BoNT-A had greater QOL improvement than those treated with urethral injection.

Electrical stimulation of sacral dermatomes can suppress aberrant urethral reflexes in felines with chronic spinal cord injury

AIMS

Uncoordinated reflex contractions of the external urethral sphincter (EUS) are a major component of voiding dysfunction after neurologic injury. Patterned stimulation of sacral afferent pathways can reduce abnormal EUS reflexes after acute spinal cord injury (SCI); however, effectiveness following chronic SCI is unknown.

METHODS

Four adult male cats were implanted with bilateral extradural sacral root electrodes to allow bladder activation and underwent subsequent spinal transection (T10-12). Nine weeks after SCI urethral and bladder pressures were recorded with and without sacral afferent stimulation. Surface electrodes were applied to sacral and lumbar dermatomes and stimulus amplitude set below the muscle fasciculation threshold. The stimulation pattern was varied by on/off times of fixed frequency at each location.

RESULTS

Reflexive EUS contractions were observed in all animals after chronic SCI. Patterned sacral dermatome stimulation reduced EUS reflex rate and amplitude in two of four cats. Suppression was dependent on both the stimulus location and pattern. Sacral locations and a stimulation pattern of (0.75 sec on, 0.25 sec off, 20 Hz) were effective in both responder animals.

CONCLUSIONS

Patterned sacral dermatome stimulation can reduce abnormal urethral reflexes following chronic SCI. Reflex suppression is dependent on both the stimulation location and stimulus pattern. Reduction of reflexive EUS activity after chronic SCI with this non-destructive and non-invasive approach may provide an advance for the treatment of detrusor-sphincter-dyssynergia.

Botulinum toxin injection for lower urinary tract dysfunction

Botulinum toxin has been recently accepted as a novel treatment for lower urinary tract dysfunctions refractory to conventional treatment. Review of the clinical trials in recent years, botulinum toxin type A has been widely used in the urethra or urinary bladder to treat voiding dysfunction due to detrusor sphincter dyssynergia, incontinence due to neurogenic or idiopathic detrusor overactivity, sensory disorders such as bladder hypersensitivity, overactive bladder, and interstitial cystitis/painful bladder syndrome. Intravesical botulinum toxin type A injection is effective in treatment of urinary incontinence due to detrusor overactivity in men and women, as well as in children. Currently botulinum toxin type A has also been applied to treat lower urinary tract symptoms due to benign prostatic hyperplasia in patients not suitable for surgery. This article reviewed the recent advances of botulinum toxin type A on lower urinary tract dysfunction.

Surgical procedures used for post-traumatic neurogenic bladder in a cat: report case

A 1-year-old castrated crossbred male cat was referred to the Veterinary Teaching Hospital for evaluation of urinary retention associated with a subluxation at T12-T13 caused by a car accident. Urethral sphincter denervation by transection of hypogastric and pudendal nerves was performed to allow bladder emptying, but after three months post operation the cat had a urinary retention recurrence. Endoscopic urethral sphincterotomy was done resulting in urinary incontinence for four months.

Effect of repeated detrusor onabotulinumtoxinA injections on bladder and renal function in patients with chronic spinal cord injuries

AIMS

To investigate the therapeutic effects of repeated detrusor onabotulinumtoxinA injections on urinary incontinence and renal function in patients with chronic spinal cord injuries (SCI).

METHODS

Patients with suprasacral SCI were enrolled. OnabotulinumtoxinA 200  U detrusor injections were repeated every 6 months for four times. Patients were instructed to perform clean intermittent catheterization during the treatment and follow-up periods. Videourodynamic study and 99mTc-DTPA renal scanning for glomerular filtration rate (GFR) were performed at screening and every 3 months to assess the therapeutic effects on bladder and renal function. Quality of life was measured by the UDI-6, IIQ-7, and self-assessed QoL indices. Adverse events were also recorded.

RESULTS

A total of 33 patients completed the study, 30 had improvement in incontinence grade (n = 18) or became completely dry (n = 12) after initial and subsequent onabotulinumtoxinA injections. Mean bladder capacity increased from 207  ±  111 to 412  ±  33  ml and mean detrusor pressure decreased from 39.8  ±  21.7 to 20.6  ±  19.1  cmH(2) O (all P < 0.05). However, the mean GFR decreased from 93.4  ±  20.4 to 83.5 ±  24  ml/min (P = 0.028). A significant reduction in GFR was noted in patients with bladder compliance that increased by <10  cmH(2) O (P = 0.002) and in patients with Pdet decreased by <10  cmH(2) O after treatment (P = 0.036). All 30 patients with improvement in incontinence grade satisfied with treatment result.

CONCLUSION

This pilot study revealed that repeated detrusor injections of 200  U onabotulinumtoxinA could reduce incontinence grade, increase bladder capacity, and decrease intravesical pressure but this study did not demonstrate an improvement in GFR over a 24-month period in patients with chronic SCI.

A systematic review of the management of autonomic dysreflexia after spinal cord injury

OBJECTIVE

To review systematically the clinical evidence on strategies to prevent and manage autonomic dysreflexia (AD).

DATA SOURCES

A key word search of several databases (Medline, CINAHL, EMBASE, and PsycINFO), in addition to manual searches of retrieved articles, was undertaken to identify all English-language literature evaluating the efficacy of interventions for AD.

STUDY SELECTION

Studies selected for review included randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies. Treatments reviewed included pharmacologic and nonpharmacologic interventions for the management of AD in subjects with spinal cord injury. Studies that failed to assess AD outcomes (eg, blood pressure) or symptoms (eg, headaches, sweating) were excluded.

DATA EXTRACTION

Studies were critically reviewed and assessed for their methodologic quality by 2 independent reviewers.

DATA SYNTHESIS

Thirty-one studies were assessed, including 6 RCTs. Preventative strategies to reduce the episodes of AD caused by common triggers (eg, urogenital system, surgery) primarily were supported by level 4 (pre-post studies) and level 5 (observational studies) evidence. The initial acute nonpharmacologic management of an episode of AD (ie, positioning the patient upright, loosening tight clothing, eliminating any precipitating stimulus) is supported by clinical consensus and physiologic data (level 5 evidence). The use of antihypertensive drugs in the presence of sustained elevated blood pressure is supported by level 1 (prazosin) and level 2 evidence (nifedipine and prostaglandin E(2)).

CONCLUSIONS

A variety of options are available to prevent AD (eg, surgical, pharmacologic) and manage the acute episode (elimination of triggers, pharmacologic); however, these options are predominantly supported by evidence from noncontrolled trials, and more rigorous trials are required.

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.

Botulinum toxin in paediatric urology: a systematic literature review

The use of botulinum toxin in paediatric urology has become increasingly widespread during recent years; however, the evidence base for its clinical use has been from adult urology centres and trials. The mechanism of action of this potent neurotoxin is discussed and evidence for its efficacy and safety is reviewed in both the adult and paediatric literature. Second, an electronic literature search was performed using the keywords paediatric urology, botulinum toxin, bladder, sphincter, and voiding dysfunction (excluding abstracts, letters and case reports). A total of 225 children in 10 peer-reviewed publications were evaluated with 165 paediatric patients with neurogenic overactivity (6 studies), 21 patients with idiopathic overactivity (1 study) and 39 patients with voiding dysfunction (3 studies). Specifically, we discuss the main indications of intravesical injections for detrusor overactivity and of intrasphincteric injections for refractory voiding dysfunctions in the paediatric population.