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Chiu PY, Liao JC. Surgical outcomes in thoracolumbar fractures with pure conus medullaris syndrome. Biomed J 2019; 42:277-284. [PMID: 31627870 PMCID: PMC6818151 DOI: 10.1016/j.bj.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/03/2018] [Accepted: 02/21/2019] [Indexed: 02/05/2023] Open
Abstract
Background Pure conus medullaris syndrome is defined as a combination of signs and symptoms of bladder/bowel incontinence and impotence without the presence of lower limbs weakness. The purpose of the study is to assess the recovery of voiding, sexual, and sensory function in patients with isolated conus medullaris syndrome after surgical treatments. Methods From January 2005 to December 2012, patients with a single level burst fracture with pure conus medullaris syndrome were assessed. Level of injury, use of steroid, surgical time, surgical approach, preoperative radiographic parameters, and types of neurogenic bladder were recorded. Bladder function was evaluated using urodynamic study; sexual function was assessed by self-report questionnaire. The final outcomes were focused on the recovery of voiding, sexual, and sensory function. Results Eight patients met the criteria of pure conus medullaris syndrome with thoracolumbar burst fracture. The injury level were all located at L1 vertebra. There were 6 males and 2 females. Four patients had overactive neurogenic bladder, and the other 4 patients had underactive type. At final, five patients regained self-voiding function, and three required intermittent catheterization. Two male patients were sexually active, and four male patients had some sexual dysfunction. Two female patients could have normal sexual intercourse but the frequency decreased. One female patients had prolonged perineum numbness at final follow-up. Conclusions Although extremely rare, pure conus medullaris syndrome may occur with L1 burst fracture. Despite surgical treatment, only one half of the patients regained normal bladder and sexual function.
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Affiliation(s)
- Ping-Yeh Chiu
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jen-Chung Liao
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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A randomized double-blind, placebo-controlled, cross-over trial assessing the effect of tadalafil (Cialis) on the cardiovascular response in men with complete spinal cord injury above the sixth thoracic level: A Pilot Study. Spinal Cord Ser Cases 2018; 4:105. [PMID: 30479838 PMCID: PMC6249218 DOI: 10.1038/s41394-018-0137-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/09/2018] [Accepted: 11/01/2018] [Indexed: 12/02/2022] Open
Abstract
Study design Double-blind, randomized cross-over placebo-controlled pilot study. Objectives To determine the effects of tadalafil on systolic blood pressure (SBP), heart rate (HR), and dizziness of men with American Spinal Injury Association Impairment Scale-A (AIS-A) spinal cord injury (SCI) between cervical-4 (C4) and thoracic-5 (T5) levels. Setting Outpatient rehabilitation clinic. Design Double-blind, randomized cross-over placebo-controlled pilot study. Methods 20 males with AIS-A SCI, C4-T5 received either tadalafil 20 mg or placebo for the first arm, and then were crossed-over after 1 week to the second arm. SBP, HR, and Visual Analogue Scale (VAS) for dizziness upon sitting up from lying were measured at baseline and again 1, 2, 4, 12, 22, 29, and 36 h post dose administration. The change in each outcome measure (SBP, HR, VAS dizziness) was observed from pre-dose to each time point. A change in VAS dizziness of 2 cm or greater (scale 0–10 cm) was considered positive. Results SBP did not change significantly in either group. However, HR increased significantly in the tadalafil group at several time points (12 h p < 0.05, 22 h p <0.05, 29 h p <0.01, and 36 h p <0.05), with no change in the placebo group. The VAS dizziness significantly increased (range 2–6 cm changes) at some time point in 1/4 of the subjects after tadalafil, but not in the placebo group; all reports of dizziness were at 12 h or later. Conclusions Tadalafil use in people with SCI above T6 is safe with respect to not causing hypotension; hemodynamic changes that occurred 12–36 h post administration were compensated for by elevations in HR. Sponsorship The Manitoba Medical Services Foundation and the Health Sciences Centre Foundation.
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Intracavernous Injections in Spinal Cord Injured Men With Erectile Dysfunction, a Systematic Review and Meta-Analysis. Sex Med Rev 2016; 4:257-269. [DOI: 10.1016/j.sxmr.2016.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 01/08/2023]
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Efficacy and safety of phosphodieterase-5 inhibitors for treatment of erectile dysfunction secondary to spinal cord injury: a systemic review and meta-analysis. Spinal Cord 2016; 54:494-501. [PMID: 26882490 DOI: 10.1038/sc.2016.3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/12/2015] [Accepted: 01/05/2016] [Indexed: 12/14/2022]
Abstract
STUDY DESIGN Systemic reviewObjective:We carried out a systematic review and meta-analysis to assess the efficacy and safety of phosphodieterase-5 (PDE5) inhibitors on erectile dysfunction (ED) secondary to spinal cord injury (SCI). METHODS A literature review was performed to identify all published randomized, double-blind, placebo-controlled trials of PDE5 inhibitors for treatment of ED secondary to SCI. The search included the following database: MEDLINE, EMBASE and the Cochrane Library. The outcomes and complications analyzed involved the Global Efficacy Question (GEQ), sexual encounter profile diary question 2 and 3 (SEP2 and SEP3) and adverse events. All statistical analysis was performed using Stata 12.0 software (Stata Corp., College Station, TX, USA). RESULTS Six publications were used in analysis, including six randomized controlled trials that compared PDE5 inhibitors with placebo. Compared with placebo, PDE5 inhibitors were associated with significant improvements in GEQ (OR 11.997, 95% CI 8.073-17.830, P<0.0001), SEP2 (RR 1.847, 95% CI 1.561-2.185, P<0.0001) and SEP3 (RR 2.738, 95% CI 2.084-3.598, P<0.0001). Despite significant greater incidences of some adverse events observed (headache: RR 3.717, 95% CI 2.309-5.982, P<0.0001; flushing: RR 9.281, 95% CI 2.858-30.147, P<0.0001; gastrointestinal discomfort: RR 9.064, 95% CI 2.116-38.827, P=0.003), most adverse events were mild to moderate and transient. CONCLUSIONS This systematic review and meta-analysis indicate that PDE5 inhibitors are effective and well tolerated to treat ED secondary to SCI compared with placebo, as measured by response to GEQ, SEP2, SEP3 and incidence of adverse events. PDE5 inhibitors could be considered as the first choice in the treatment of ED patients with SCI.
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Courtois F, Charvier K. Sexual dysfunction in patients with spinal cord lesions. HANDBOOK OF CLINICAL NEUROLOGY 2015; 130:225-45. [PMID: 26003247 DOI: 10.1016/b978-0-444-63247-0.00013-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Many aspects of sexuality can be disrupted following a spinal cord lesion (SCL). It can alter an individual's self-esteem and body image, interfere with positioning and mobility, introduce unexpected problems with incontinence and spasticity, decrease pleasure, and delay orgasm. Sexual concerns in men can involve erectile function, essential for intercourse, ejaculation function, necessary for fertility, and the ability to reach orgasm. In women they can involve concerns with vaginal lubrication, genital congestion, and vaginal infections, which can all go unnoticed, and orgasm, which may be lost. All of these concerns must be addressed during rehabilitation as individuals with SCL continue to live an active sexual life, and consider sexuality among their top priority for quality of life. This chapter describes the impact of SCL on various phases of men's and women's sexual responses and on various aspects of sexuality. Treatments are described in terms of what is currently available and what is specific to the SCL population. New approaches in particular for women are described, along with tips from sexual counseling which consider an overall approach, taking into account the primary, secondary, and tertiary consequences of the SCL on the individual's sexuality. Throughout the chapter, attempts are made to integrate neurophysiologic knowledge, findings from the literature on SCL, and clinical experience in sexual rehabilitation.
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Affiliation(s)
- Frédérique Courtois
- Department of Sexology, Université du Québec à Montréal, Montreal, Quebec, Canada.
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Courtois F, Charvier K, Leriche A, Vézina JG, Jacquemin G. Réactions sexuelles et orgasme chez le patient traumatisé médullaire : un modèle de rééducation/réadaptation. SEXOLOGIES 2009. [DOI: 10.1016/j.sexol.2009.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Courtois F, Charvier K, Leriche A, Vézina JG, Jacquemin G. Sexual and climactic responses in men with traumatic spinal injury: A model for rehabilitation. SEXOLOGIES 2009. [DOI: 10.1016/j.sexol.2009.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Courtois F, Charvier K, Leriche A, Côté M, Lemieux A. L’évaluation et le traitement des troubles des réactions sexuelles chez l’homme et la femme blessés médullaires. SEXOLOGIES 2009. [DOI: 10.1016/j.sexol.2007.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Courtois FJ, Charvier KF, Leriche A, Vézina JG, Côté M, Bélanger M. Blood pressure changes during sexual stimulation, ejaculation and midodrine treatment in men with spinal cord injury. BJU Int 2007; 101:331-7. [PMID: 17922856 DOI: 10.1111/j.1464-410x.2007.07254.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore the effectiveness of various sources of self-stimulation, including oral midodrine, in triggering ejaculation in men with spinal cord injury (SCI), and to document the systematic variations in blood pressure at ejaculation and consider a revised definition of autonomic dysreflexia. PATIENTS AND METHODS The study included 62 men with SCI lesions from C2 to L2. Ejaculation potential was assessed with various sources of stimulation, beginning with natural stimulation, followed, if the test was negative, by penile vibrator stimulation (PVS) followed, if the test was again negative, by PVS combined with oral midodrine, started at 5 mg and increased in 5 mg steps up to 25 mg. The success rate of ejaculation was recorded, as were blood pressure (BP) changes measured at baseline and at ejaculation (or on the last trial if the test was negative). Reported sensations were also recorded and compared during positive and negative tests. RESULTS Overall, 89% of the patients reached ejaculation with one mode or another of stimulation. When patients had a negative result with natural stimulation, 56% were salvaged by PVS, and when PVS was negative, another 22% were salvaged by midodrine combined with PVS. The mean systolic BP increased by 35 mmHg at ejaculation during PVS and by 11 mmHg after midodrine, and a subsequent 29 mmHg at ejaculation during PVS combined with midodrine. By contrast, negative tests showed a relatively stable BP; the difference in changes in BP during positive and negative tests was significant (P < 0.01). Increases in BP during positive tests declined significantly more often within the limits of autonomic dysreflexia than negative tests (P < 0.01). CONCLUSION These results support the view that most men with SCI can obtain an ejaculation when a wide spectrum of stimulation is used, including natural stimulation, PVS, and PVS combined with oral midodrine. Positive tests were associated with significant increases in BP, in contrast to negative tests, where BP was relatively stable. This suggests that significant changes in BP are required for ejaculation and that insignificant changes are predictive of future failure. As most changes in BP during positive tests also fall within the criterion of autonomic dysreflexia, a revised definition of autonomic dysreflexia should be considered to encourage safe experiences with ejaculation and safe use of midodrine.
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Giuliano F, Denys P, Soler JM, Chartier-Kastler E, Leriche A, Ruffion A. Chapitre A - Les dysfonctions sexuelles masculines et leurs traitements en neuro-urologie. Prog Urol 2007; 17:619-21. [PMID: 17622099 DOI: 10.1016/s1166-7087(07)92377-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The management of sexual dysfunction has been revolutionized over recent years with the arrival of new treatments for erectile dysfunction. In parallel, groups specialized in neurosexology have gradually emerged in order to improve the patient's fertility. This article presents the disorders most frequently encountered in spinal cord injury and the main approaches to management.
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Affiliation(s)
- F Giuliano
- Service de médecine physique et de réadaptation, Raymond Poincaré, Université Versailles Saint-Quentin en Yvelines, Garches, France.
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Abstract
This special report traces the path of spinal cord injury (SCI) from ancient times through the present and provides an optimistic overview of promising clinical trials and avenues of basic research. The spinal cord injuries of Lord Admiral Sir Horatio Nelson, President James A. Garfield, and General George Patton provide an interesting perspective on the evolution of the standard of care for SCI. The author details the contributions of a wide spectrum of professionals in the United States, Europe, and Australia, as well as the roles of various government and professional organizations, legislation, and overall advances in surgery, anesthesia, trauma care, imaging, pharmacology, and infection control, in the advancement of care for the individual with SCI.
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Affiliation(s)
- William H Donovan
- The Institute for Rehabilitation and Research, Houston, Texas, Houston, Texas, USA.
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Courtois F, Geoffrion R, Landry E, Bélanger M. H-reflex and physiologic measures of ejaculation in men with spinal cord injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated. Arch Phys Med Rehabil 2004; 85:910-8. [PMID: 15179644 DOI: 10.1016/j.apmr.2003.05.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the various physiologic parameters characterizing and predicting ejaculation. DESIGN Single case-control study. SETTING A referred care center and university setting. PARTICIPANTS Two men with spinal cord injury (SCI) and 2 control subjects. INTERVENTION Subjects were asked to self-stimulate with a Ferticare vibrator to induce ejaculation over 5 to 8 independent sessions. MAIN OUTCOME MEASURES Penile tumescence, blood pressure, heart rate, electromyographic activity of the bulbocavernosus muscles, abdominal muscles, soleus H-reflex, and occurrence of ejaculation. RESULTS Changes on all measures were observed, with penile tumescence being more stable in control subjects. Blood pressure increased in both groups, whereas tachycardia was observed in controls and bradycardia in subjects with SCI. H-reflex dropped slightly in controls but increased in subjects with SCI. Muscular patterns differed on ejaculatory success or failure. CONCLUSIONS Physiologic changes on all measures can be observed in men with SCI as a function of ejaculation. Changes include hypertension and bradycardia, characteristic of hyperreflexia, and tachycardia in controls. The neural mechanisms underlying these patterns are discussed. H-reflex showed increased spinal cord excitability in subjects with SCI after ejaculation, which suggests spasticity. The results support investigation of the H-reflex to predict ejaculatory success or failure in men with SCI, along with specific analysis of muscular patterns.
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Affiliation(s)
- Frédérique Courtois
- Department of Sexology, Université du Québec à Montréal, CP 8888, Succursale Centre Ville, Montréal, Québec H3C 3P8, Canada.
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Abstract
Neurologic erectile dysfunction presents a diagnostic and treatment challenge to the internist and urologist. Multiple chronic disease modalities and traumatic etiologies exist. Education regarding these conditions and a detailed and thorough history and office work-up are the best resources for the clinician. Treatment can follow the model of proceeding from the least to most invasive procedure (process of care), taking into account patient and partner satisfaction. Because the psychology of grief and loss may enter into treatment of some neurologic conditions (e.g., erectile dysfunction after radical retropubic prostatectomy, spinal cord injury, or chronic diseases), a whole-patient approach encompassing psychotherapy is warranted.
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Affiliation(s)
- A Nehra
- Department of Urology, Mayo Medical School, and Mayo Clinic and Foundation, Rochester, Minnesota, USA.
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