Inguinal Canal Dilatation: A Novel Technique for the Repair of Failed Testicular Descent despite Hormonal Treatment

Treatment of the undescended testicle (UT) after it failed to descend on hormonal therapy is surgical. Spermatic cord elongation may impair testicular function, particularly in cases in which cord integuments or veins have to be divided to provide an extra cord length. A factor that might impede testicular descent is presence of a narrowed or obliterated inguinal canal. We investigated the hypothesis that dilatation of a narrowed or obliterated inguinal canal might assist spontaneous testicular descent. Twenty-six boys (age 3.6 ± 0.8 years) with unilateral UT and failed hormonal treatment, whose UT was located at deep inguinal ring, were included in the study. Through an inguinal incision, the inguinal canal was dilated, spermatic cord adhesions divided, hernial sac, if present, excised, and skin closed. Testicular descent into the scrotum occurred in 22 patients within 4.2 ± 1.3 months. The remaining four patients were reoperated on by Fowler-Stephens orchiopexy after 14 months. A technique is presented for the treatment of the UT after failure to respond to hormonal treatment. It consisted of clearing the testicular pathway of any adhesions and dilating the narrowed inguinal canal. The technique is simple, easy, and does not interfere with the testicle or spermatic cord.

Contraction of Gluteal Maximus Muscle on Increase of Intra-Abdominal Pressure: Role in the Fecal Continence Mechanism

The gluteus maximus muscle (GMM) appears to contract with increased intra-abdominal pressure (IAP). The hypothesis that GMM contraction with increased IAP was investigated. The study comprised 32 healthy volunteers. IAP was measured by intravesical catheter. The response of electromyography of the GMM and external anal sphincter to sudden momentary and slow sustained straining was registered. The procedure was repeated after individual urinary bladder and GMM anesthetization. Sudden straining increased electromyographic activity of the external anal sphincter and GMM. Slow, sustained straining raised electromyographic activity of the gluteus maximus and external sphincter at differing degrees depending on straining intensity. The anesthetized gluteus maximus or urinary bladder did not respond to straining. The suggested GMM contraction on straining seems mediated through a reflex that is called “straining-gluteal reflex.” This reflex appears to assist anal closure through extended and laterally rotated femur induced by gluteus contraction.

Rectocele repair with stapled transvaginal rectal resection

BACKGROUND

Constipation is a clinical symptom in patients suffering from slow transit and/or obstructed defecation. Proper treatment requires the identification of all associated disorders and the quantification of symptoms. Rectocele can cause the symptoms of obstructed defecation syndrome (ODS). The aim of this study was to evaluate the clinical and functional outcomes of a novel technique of transvaginal stapled rectal resection (TVSRR) using a straight staple line, to treat rectocele.

METHODS

The study included 84 females [median age 51 years (range 29-73 years)], with obstructed defecation, grades II-III rectocele, and multiple abnormalities on defecography. The magnitude and degree of ODS were quantified by the Altomare ODS scoring system. Continence status was evaluated using the Pescatori scoring system. The rectal and vaginal manometric study, the index of patient satisfaction using a visual analog score (VAS), and the validated Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire results were recorded. All patients underwent TVSRR.

RESULTS

There were no intraoperative complications. Early postoperative complications were defecatory urgency in seven patients (8.3 %), dyspareunia in two (2.4 %), and rectovaginal fistula in one (1.2 %). Five patients (6 %) had recurrence of ODS symptoms. There was no significant change in continence pre- and postoperatively. The ODS score and VAS revealed significant improvement within the first postoperative year in 94 % of patients. The PAC-QOL questionnaire mean total scores indicated an improvement in both the patient satisfaction and the QOL during the 12-month follow-up. The self-reported definitive outcome was excellent in 46 patients (54.7 %), good in 29 (34.5 %), fairly good in 20 (23.8 %), and poor in five (6.0 %).

CONCLUSIONS

Vaginal repair carries no risk of fecal incontinence. Large anterior rectocele is considered the main indication for this technique. Using the linear stapler is a cost-effective, simple, and easy technique.

On the etiology of the electric activity of the external anal and urethral sphincters

In a previous study, the external anal sphincter (EAS) in dogs, known to consist of skeletal muscle fibers, was proved to contain bundles of smooth muscle fibers in between as well.

OBJECTIVE

Cause of electric activity in the external anal and urethral sphincters is not known; the current study investigated this point.

MATERIAL AND METHODS

Slices from external anal and urethral sphincters of 21 cadavers (12 male, 9 female). Eighth were fully and mat wide neonates, 13 were adults, were stained with hematoxylin and eosin, Masson's trichrome and succinic dehydrogenase, and examined microscopically. Eighteen healthy volunteers, electromyography activity of their external anal and urethral sphincters was recorded at rest, on coughing, after pudendal nerve block and after drotaverine administration, (a smooth muscle relaxant). Anal and urethral pressures were also measured.

RESULTS

Microscopic studies have shown that both external anal and urethral sphincters were formed of bundles of smooth muscle fibers present in between the skeletal muscle fibers. Bilateral pudendal nerve block did not abolish the external anal or the urethral sphincters electromyography activity at rest, or on coughing, and did not cause significant anal or urethral pressure changes (p > .05). Drotaverine administration lead to disappearance of the electromyography activity and significant decline of the anal and urethral pressures (p < .05). The results were reproducible when the tests were repeated in the same subject.

CONCLUSION

Histologic examination revealed the presence of smooth muscle fibers, between the skeletal fibers of the external anal and urethral sphincters. Evidence suggests that the smooth muscle fibers are the source of the electric activity of the sphincters and might explain some physiologic phenomena such as the external anal contraction on rectal distension or on coughing.

Tunica albuginea reefing: a novel technique for the treatment of erectile dysfunction

BACKGROUND

"Tunica albuginea (TA) reefing" is a modification of Shafik's "TA overlapping" operation. Both techniques are based on the fact that in venogenic erectile dysfunction patients, the TA exhibits degenerative and atrophic collagen and elastic fibers causing its subluxation and flabbiness. This had led to loss of the veno-occlusive mechanism of the TA and venous leakage during erection.

AIM

Reefing of the redundant tissue by bilateral excision of an ellipse of the TA provides a more effective correction of the TA and achieves a good support of the corpora cavernosa during tumescence.

MATERIAL AND METHODS

The study included 24 patients with a mean age of 33.5 ± 1.7 SD years. Intracorporal pressure was measured preoperatively and postoperatively. After penile degloving, an ellipse was excised from both lateral aspects of the penile shaft, extending from the glans penis to its root, and the two edges of each wound were reefed by continuous Dexon suture.

RESULTS

The TA ellipses were taken as biopsies and revealed degenerative changes when stained with hematoxylin and eosin and Masson's trichrome stain. Postoperatively, there was an intracorporal pressure increase (p < .01) in 20 out of 24 patients of the study and a decrease in 4 out of 24. Six months after operation, the patients showed significantly (p < .01) improved scores for the domain of erectile function over the preoperative scores.

CONCLUSION

The reefing operation corrects the TA flabbiness to a greater extent, lends more support to corporal tissue, and improves the veno-occlusive mechanism.

The “Opening Time” and “Pelvic Floor Electromyographic Lag Time”: Two Novel Tools in the Assessment of the Anorectal Evacuation Time

Rectal evacuation necessitates rectal contraction and pelvic floor muscles relaxation; it is not known which action precedes the other. We investigated the hypothesis that pelvic floor muscles relaxation precedes rectal contraction so that rectal contents find the anal canal already opened. Electromyographic activity of the external anal sphincter as well as anal and rectal pressures were recorded during rectal balloon distension and evacuation. Pelvic floor muscles electromyographic lag time (time from start of pelvic floor muscles relaxation to start of evacuation) and opening time (time from start of rectal contraction to start of evacuation) were measured. Rectal balloon distension in increments of 20 mL up to 100 mL effected progressive increase of both external anal sphincter electromyography and anal pressure. At 120 mL balloon distension up to 180 mL, external anal sphincter electromyography and anal pressure exhibited gradual decrease whereas rectal pressure showed no changes. At 200 to 220 mL rectal balloon distension, rectal pressure increased and anal pressure decreased, while external anal sphincter showed no electromyographic activity; rectal balloon was expelled. The opening time recorded a mean of 1.8 +/- 0.7 s and pelvic floor muscles electromyographic lag time of 2.2 +/- 0.9; the two recordings showed no significant difference (p > .05). These, two diagnostic tools in anorectal investigations are presented: the opening time and pelvic floor muscles electromyographic lag time. Pelvic floor muscles relaxation preceded rectal contraction. As there is no significant difference between opening time and pelvic floor muscles electromyographic lag time, it appears easier to apply the latter as it is simple, objective, and noninvasive.

Double-loop puborectoplasty: novel technique for the treatment of fecal incontinence

The treatment of neurogenic and traumatic fecal incontinence (FI) as may result from severe anal sphincteric destruction is problematic. A novel technique for the treatment of these cases is presented. The study comprised 44 patients, which included 28 with neurogenic and 16 with traumatic FI. Patients were divided into two equal groups. Two fascia lata slings (FLS) were applied in Group 1, while one sling was used in Group 2. Investigations comprised manometric and electromyographic studies. The procedure consisted of performing a curvilinear incision behind the anal orifice, and the supralevator region was entered. The middle of an FLS was sutured to the back of the upper part of anal canal. Each of the two limbs of the sling was passed forward through an incision on the pubic ramus and was sutured to the periosteum of the pubic ramus. This was preformed in Groups 1 and 2. A second FLS was added in Group 1. Its center was sutured to the front of the mid anal canal and its two limbs to the coccyx. Satisfactory results (continence scores 1 and 2) were obtained in 63.6% of Group 1 and 36.4% of Group 2. Significant postoperative anal pressure increase occurred in scores 1 to 3 in Group 1 and in scores 1 to 2 in Group 2. Anal pressure increase was more prominent in Group 1 than in Group 2. The continent effect of the operation appears to be due to the increase of anal pressure, anal canal elongation, and recto-anal angulation. The operation is indicated in FI of the idiopathic or traumatic type with excessive sphincteric loss. It is simple and easy and performed under no cover of colostomy.

An electrophysiologic study of female ejaculation

Opinions vary over whether female ejaculation exists or not. We investigated the hypothesis that female orgasm is not associated with ejaculation. Thirty-eight healthy women were studied. The study comprised of glans clitoris electrovibration with simultaneous recording of vaginal and uterine pressures as well as electromyography of corpus cavernous and ischio- and bulbo-cavernosus muscles. Glans clitoris electrovibration was continued until and throughout orgasm. Upon glans clitoris electrovibration, vaginal and uterine pressures as well as corpus cavernous electromyography diminished until a full erection occurred when the silent cavernosus muscles were activated. At orgasm, the electromyography of ischio-and bulbo-cavernosus muscles increased intermittently. The female orgasm was not associated with the appearance of fluid coming out of the vagina or urethra.

Effect of thermal cutaneous stimulation on the gastric motor activity: Study of the mechanism of action

AIM: To investigate the mechanism of action of thermal cutaneous stimulation on the gastric motor inhibition.

METHODS: The gastric tone of 33 healthy volunteers (20 men, mean age 36.7 ± 8.4 years) was assessed by a barostat system consisting of a balloon-ended tube connected to a strain gauge and air-injection system. The tube was introduced into the stomach and the balloon was inflated with 300 mL of air. The skin temperature was elevated in increments of 3°C up to 49°C and the gastric tone was simultaneously assessed by recording the balloon volume variations expressed as the percentage change from the baseline volume. The test was repeated after separate anesthetization of the skin and stomach with lidocaine and after using normal saline instead of lidocaine.

RESULTS: Thermal cutaneous stimulation resulted in a significant decrease of gastric tone 61.2% ± 10.3% of the mean baseline volume. Mean latency was 25.6 ± 1.2 ms. After 20 min of individual anesthetization of the skin and stomach, thermal cutaneous stimulation produced no significant change in gastric tone.

CONCLUSION: Decrease in the gastric tone in response to thermal cutaneous stimulation suggests a reflex relationship which was absent on individual anesthetization of the 2 possible arms of the reflex arc: the skin and the stomach. We call this relationship the “cutaneo-gastric inhibitory reflex”. This reflex may have the potential to serve as an investigative tool in the diagnosis of gastric motor disorders, provided further studies are performed in this respect.

Study of the response of the penile corporal tissue and cavernosus muscles to micturition

BACKGROUND

The reaction of the corpora cavernosa (CC), the corpus spongiosum (CS), the bulbocavernosus (BCM) and ischiocavernosus (ICM) muscles to passage of urine through the urethra during micturition is not known. We investigated the hypothesis that the passage of urine through the urethra stimulates the corporal tissue and cavernosus muscles.

METHODS

In 30 healthy men (mean age 42.8 +/- 11.7 years), the electromyographic activity (EMG) of the CC, CS, BCM, and ICM were recorded before and during micturition, and on interruption of and straining during micturition. These tests were repeated after individual anesthetization of urethra, corporal tissue, and cavernosus muscles.

RESULTS

During micturition, the slow wave variables (frequency, amplitude, conduction velocity) of the CC and CS decreased while the motor unit action potentials of the BCM and ICM increased; these EMG changes were mild and returned to the basal values on interruption or termination of micturition. Micturition after individual anesthetization of urethra, corporal tissue and cavernosal muscles did not effect significant EMG changes in these structures, while saline administration produced changes similar to those occurring before saline administration.

CONCLUSION

The decrease of sinusoidal and increase of cavernosus muscles' EMG activity during micturition apparently denotes sinusoidal relaxation and cavernosus muscles contraction. Sinusoidal muscle relaxation and cavernosus muscles contraction upon micturition are suggested to be mediated through a 'urethro-corporocavernosal reflex'. These sinusoidal and cavernosus muscle changes appear to produce a mild degree of penile tumescence and stretch which might assist in urinary flow during micturition.

Percutaneous perineal electrostimulation induces erection: clinical significance in patients with spinal cord injury and erectile dysfunction

OBJECTIVES

Approximately one third to one half of the penis is embedded in the pelvis and can be felt through the scrotum and in the perineum. The main arteries and nerves enter the penis through this perineal part of the penis, which seems to represent a highly sensitive area. We investigated the hypothesis that percutaneous perineal stimulation evokes erection in patients with neurogenic erectile dysfunction.

METHODS

Percutaneous electrostimulation of the perineum (PESP) with synchronous intracorporeal pressure (ICP) recording was performed in 28 healthy volunteers (age 36.3 +/-7.4 y) and 18 patients (age 36.6 +/- 6.8 y) with complete neurogenic erectile dysfunction (NED). Current was delivered in a sine wave summation fashion. Average maximal voltages and number of stimulations delivered per session were 15 to 18 volts and 15 to 25 stimulations, respectively.

RESULTS

PESP of healthy volunteers effected an ICP increase (P < 0.0001), which returned to the basal value upon stimulation cessation. The latent period recorded was 2.5 +/- 0.2 seconds. Results were reproducible on repeated PESP in the same subject but with an increase of the latent period. Patients with NED recorded an ICP increase that was lower (P < 0.05) and a latent period that was longer (P < 0.0001) than those of healthy volunteers.

CONCLUSION

PESP effected ICP increase in the healthy volunteers and patients with NED. The ICP was significantly higher and latent period shorter in the healthy volunteers than in the NED patients. PESP may be of value in the treatment of patients with NED, provided that further studies are performed to reproduce these results.

Inguinal canal dilatation: a novel technique for the repair of failed testicular descent despite hormonal treatment

Treatment of the undescended testicle (UT) after it failed to descend on hormonal therapy is surgical. Spermatic cord elongation may impair testicular function, particularly in cases in which cord integuments or veins have to be divided to provide an extra cord length. A factor that might impede testicular descent is presence of a narrowed or obliterated inguinal canal. We investigated the hypothesis that dilatation of a narrowed or obliterated inguinal canal might assist spontaneous testicular descent. Twenty-six boys (age 3.6 +/- 0.8 years) with unilateral UT and failed hormonal treatment, whose UT was located at deep inguinal ring, were included in the study. Through an inguinal incision, the inguinal canal was dilated, spermatic cord adhesions divided, hernial sac, if present, excised, and skin closed. Testicular descent into the scrotum occurred in 22 patients within 4.2 +/- 1.3 months. The remaining four patients were reoperated on by Fowler-Stephens orchiopexy after 14 months. A technique is presented for the treatment of the UT after failure to respond to hormonal treatment. It consisted of clearing the testicular pathway of any adhesions and dilating the narrowed inguinal canal. The technique is simple, easy, and does not interfere with the testicle or spermatic cord.

A novel concept for the surgical anatomy of the perineal body

PURPOSE

Perineal body is considered by investigators as a fibromuscular structure that is the site of insertion of perineal muscles. We investigated the hypothesis that perineal body is the site across which perineal muscles pass uninterrupted from one side to the other.

METHODS

Perineal body was studied in 56 cadaveric specimens (46 adults, 10 neonatal deaths) by direct dissection with the help of magnifying loupe, fine surgical instruments, and bright light.

RESULTS

Perineal body consisted of three layers: 1) superficial layer, which consisted of fleshy fibers of the external anal sphincter extending across perineal body to become the bulbospongiosus muscle; 2) tendinous extension of superficial transverse perineal muscle crossing perineal body to contralateral superficial transverse perineal muscle, with which it formed a criss-cross pattern; and 3) tendinous fibers of the deep transverse perineal muscle; the fibers crossing perineal body decussated in criss-cross pattern with the contralateral deep transverse perineal muscle. A relation of levator ani or puborectalis muscles to perineal body could not be identified.

CONCLUSIONS

Perineal body (central perineal tendon) is not the site of insertion of perineal muscles but the site along which muscle fibers of these muscles and the external anal sphincter pass uninterrupted from one side to the other. Such a free passage from one muscle to the other seems to denote a "digastric pattern" for the perineal muscles. Perineal body is subjected to injury or continuous intra-abdominal pressure variations, which may eventually result in perineocele, enterocele, or sigmoidocele.

Electromyographic Activity of the Anterolateral Abdominal Wall Muscles During Rectal Filling and Evacuation

BACKGROUND

The role of the anterolateral abdominal wall muscles (AAWMs) at defecation has not received sufficient attention in the literature. We investigated the hypothesis that the AAWMs exhibit increased electromyographic (EMG) activity on rectal distension, which presumably assists in rectal evacuation.

MATERIALS AND METHODS

The effect of rectal balloon distension on the AAWMs EMG and on anal and rectal pressure was examined in 23 healthy volunteers (37.2 +/- 9.4 SD years, 14 men, 9 women); this effect was tested before and after rectal and AAWMs anesthetization.

RESULTS

The rectal and anal pressures increased gradually upon incremental rectal balloon distension starting at 70 mL balloon distension until, at a mean of 113.6 +/- 5.6 mL, the balloon was expelled to the exterior. The AAWMs showed no EMG activity at rest or on rectal distension up to the time of balloon expulsion when they exhibited significant increase of EMG. This effect was abolished on individual rectal or AAWMs anesthetization but not with saline administration.

CONCLUSIONS

AAWMs appear to contract simultaneously with rectal contraction; this action seems to increase the intra-abdominal pressure and assist rectal evacuation. The AAWMs contraction upon rectal contraction appears to be mediated through a reflex, which we call the "recto-abdominal wall reflex". Further studies are required to investigate the role of this reflex in defecation disorders.

Identification of a vaginal pacemaker: An immunohistochemical and morphometric study

Vaginal electric waves spread caudally in the vagina. We investigated the hypothesis that electric waves originate from a centre of interstitial cells of Cajal (ICCs) in the proximal vagina. Specimens (0.75 x 0.75 cm) were obtained from the vaginal walls of 23 cadavers (age 38.2 +/- 10.2 years). Sections were prepared for immunohistochemical investigations using the specific ICC marker, C-kit. Morphometric studies for image analysis using a Leica imaging system were performed. C-kit positive cells were detected in vaginal smooth muscle. Results from image analyser revealed that mean area percent of positive immunoreactivity for C-kit in the upper part of posterior vaginal wall was significantly higher (p < 0.0001) than of areas in other vaginal walls, and also significantly higher (p < 0.05) in circular than in longitudinal muscle layer. Studies have shown that the greatest collection of ICCs occurred in the upper part of the posterior vaginal wall. The vaginal electric waves are suggested to originate from this 'centre' and spread caudally.

The effect of gastric overfilling on the pharyngo-esophageal and lower esophageal sphincter: a possible factor in restricting food intake

BACKGROUND

How afferent activity in the gut achieves the required ingestion control has not been established. The authors hypothesized that gastric overdistension effects an increase in pharyngo-esophageal and lower esophageal sphincter activity aimed at inhibiting ingestion.

MATERIAL/METHODS

The study comprised 16 mongrel dogs. Under anesthesia, one balloon-tipped catheter was placed in the stomach, another within the lower esophageal sphincter (LES), and a third within the pharyngo-esophageal sphincter (PES). The gastric balloon was filled with H(2)O in increments of 10 ml and LES and PES pressures were recorded. The test was repeated after individual gastric, LES, and PES anesthetization.

RESULTS

Gastric balloon filling with more than 20 ml of H(2)O showed progressively increasing LES pressure up to 110-120 ml of gastric filling, beyond which the pressure exhibited no further increase upon incrementally increased gastric filling volume. PES pressure increased only with a gastric filling volume exceeding 100-110 ml and continued to increase with increasing gastric filling. Gastric filling as above while the stomach, LES, and PES were separately anesthetized produced no LES or PES pressure response.

CONCLUSIONS

LES and PES appear to contract on gastric filling; PES responds only to excess gastric filling. It seems that LES and PES response to gastric filling is mediated through a reflex which the authors call the "gastro-esophagopharyngeal reflex" (GEPR). Changes in the evoked response would indicate a defect in the reflex pathway. GEPR might thus serve as an investigative tool in the diagnosis of gastroesophageal disorders, although further studies are required.

Study of the effect of ileal distension on the motor activity of the jejunum, and of jejunal distension on the motor activity of the ileum

BACKGROUND/AIMS

The effect of ileal distension on the jejunal motor activity and ofjejunal distension on the ileal motility have been poorly addressed in the literature. We investigated the hypothesis that distension of either ileum or jejunum would affect the motile activity of the other.

METHODOLOGY

Response of jejunal pressure to ileal balloon distension and of ileal pressure to jejunal distension in increments of 2 mL of normal saline were recorded in 18 dogs. The test was performed after individual local anesthetization of the ileum and jejunum and was repeated using saline instead of lidocaine.

RESULTS

Ileal distension with 2, 4, and 6mL of saline produced no jejunal pressure response (p >0.05), while 8- and up to 12-mL distension effected jejunal pressure decrease (p<0.05). Jejunal distension up to 6mL did not change ileal pressure (p>0.05); distension with 8, 10, and 12 mL reduced it (p<0.05). Jejunal or ileal pressure responses were maintained as long as ileal or jejunal distension was continued. Distension of the anesthetized ileum or jejunum did not produce significant pressure changes in either.

CONCLUSIONS

Jejunal or ileal pressure decrease and presumably hypotonia upon large-volume ileal or jejunal, respectively, distension postulate reflex relationship which we call 'ileal-jejunal and jejuno-ileal inhibitory reflex'. These reflexes appear to regulate chyme flow in small intestine by creating a balance of chyme delivery between the jejunum and ileum. Reflex derangement in neurogenic and myogenic diseases may result in gastrointestinal disorders, a point that needs to be investigated.

The effect of vaginal distension on the female urinary bladder and urethral sphincters

AIMS

A mention of effect of vaginal distension, as induced by penile thrusting at coitus, on urinary bladder (UB) and urethral sphincters could not be traced in literature. We investigated the hypothesis that, upon vaginal distension, UB undergoes inhibited activity, while external and internal urethral sphincters (IUS) exhibit increased activity in order to guard against urine leakage during coitus.

METHODS

Response of UB and external and IUS to vaginal balloon distension was recorded in 28 healthy women (age 35.6+/-3.3 years). A vaginal condom was inflated with air in increments of 50 up to 200 ml, and vesical pressure as well as electromyographic (EMG) activity of external and IUS were registered. The test was repeated after separate anaesthetisation of vagina, UB and external and IUS.

RESULTS

On vaginal distension, vesical pressure was reduced in the ratio of expansion of vaginal volume up to a certain capacity, beyond which vesical pressure ceased to decline when distending volume was augmented. Similarly, IUS EMG activity increased progressively on incrementally added vaginal distension up to 150-ml distension, beyond which any further vaginal distension did not produce an additional increase of EMG activity; the external urethral sphincter (EUS) EMG activity showed no response. Vaginal distension, while the vagina, UB and external and IUS had been separately anaesthetised, produced no significant change.

CONCLUSION

Vaginal balloon distension seems to effect vesical wall relaxation and increase IUS tone. This appears to provide a mechanism that prevents urine leak during coitus. Vesical and IUS response to vaginal distension are suggested to be mediated through a reflex we term 'vagino-vesicosphincteric reflex', which seems to be evoked by vaginal distension during penile thrusting. The reflex may prove of diagnostic significance in sexual disorders.

Duodeno-jejunal junction dyssynergia: Description of a novel syndrome

AIM: To investigate the hypothesis that duodeno-jejunal dyssynergia existed at the duodeno-jejunal junction.

METHODS: Of 112 patients who complained of epigastric distension and discomfort after meals, we encountered nine patients in whom the duodeno-jejunal junction did not open on duodenal contraction. Seven healthy volunteers were included in the study. A condom which was inserted into the 1^st duodenum was filled up to 10 mL with saline in increments of 2 mL and pressure response to duodenal distension was recorded from the duodenum, duodeno-jejunal junction and the jejunum.

RESULTS: In healthy volunteers, duodenal distension with 2 and 4 mL did not produce pressure changes, while 6 and up to 10 mL distension effected significant duodenal pressure increase, duodeno-jejunal junction pressure decrease but no jejunal pressure change. In patients, resting pressure and duodeno-jejunal junction and jejunal pressure response to 2 and 4 mL duodenal distension were similar to those of healthy volunteers. Six and up to 10 mL 1^st duodenal distension produced significant duodenal and duodeno-jejunal junction pressure increase and no jejunal pressure change.

CONCLUSION: Duodeno-jejunal junction failed to open on duodenal contraction, a condition we call ‘duodeno-jejunal junction dyssynergia syndrome’ which probably leads to stagnation of chyme in the duodenum and explains patients' manifestations.

Physiologic basis of digital-rectal stimulation for bowel evacuation in patients with spinal cord injury: identification of an anorectal excitatory reflex

BACKGROUND AND PURPOSE

Although advances in rehabilitation practices, pharmacology, and surgery offer new bowel program alternatives, digital-rectal stimulation is still utilized to facilitate defecation in patients with spinal cord injury (SCI). We speculated that defecation induced by such a technique is mediated through a reflex mechanism.

METHODS

The study comprised 18 healthy volunteers (10 men, 8 women, mean age 36.6 +/- 9.7 years) and 9 patients with SCI (6 men, 3 women, mean age 35.1 +/- 11.2 years). The anal canal was dilated by a balloon inflated in 2-mL increments to 10 mL, and rectal pressure response was then recorded. The test was repeated after separate block of the external and internal anal sphincters and after individual anesthetization of the anal canal and rectum.

RESULTS

In normal subjects, the rectal pressure rose significantly (p < 0.01) with 2-mL inflation. Increases in anal dilatation effected further rectal pressure elevations (p < 0.001), although there were no significant differences among the 4-, 6-, and 10-mL distensions (p > 0.05). The rectal pressure rise occurred with external, but not with internal, sphincter paralysis. In the subjects with paraplegia, there was no rectal pressure response to the 2- and 4-mL anal dilatations, while the 6-, 8-, and 10-mL distensions effected significant pressure increases (p < 0.001, p < 0.001, p < 0.001, respectively) that did not differ significantly among the 3 distending volumes. Internal sphincter inhibition, in contrast to the external sphincter, produced no rectal pressure response. In both normal subjects and subjects with paraplegia, the rectal pressure response did not occur after individual anesthetization of the rectum and anal canal.

CONCLUSIONS

Anal dilatation induces rectal contraction through stimulation of mechanoreceptors, possibly in the internal sphincter. Rectal contraction upon anal dilatation suggests a reflex relationship that was absent on individual anesthetization of the possible 2 arms of the reflex arc: anal canal and rectum. This relationship, which we term the "anorectal excitatory reflex," appears to be evoked on digital anal dilatation. The reflex might be of diagnostic significance in defecation disorders and has the potential to be used as an investigative tool.

The Response of the Corporal Tissue and Cavernosus Muscles to Urethral Stimulation: An Effect of Penile Buffeting of the Vaginal Introitus

We investigated the hypothesis that urethral stimulation in humans induces sexual response in the form of activation of the corporal tissue and cavernosus muscles through a reflex mechanism. Electromyographic activity of corpora cavernosa (CC), corpus spongiosum (CS), bulbocavernosus (BCM), and ischiocavernosus (ICM) muscles was recorded in 43 healthy volunteers (24 men, 19 women; age, 37.7 +/- 8.2 years) during urethral stimulation. The tests were repeated after individual anesthetization of urethra, CC, CS, BCM, and ICM. During stimulation of the distal urethra, slow wave variables of CC and CS decreased while motor unit action potentials of BCM and ICM increased. Urethral stimulation after individual anesthetization of urethra, CC, CS, BCM, and ICM did not effect significant changes in these structures, but saline administration did. Diminished electromyographic activity of CC and CS with increased activity of BCM and ICM during distal urethral stimulation presumably denotes sinusoidal muscle relaxation of CC and CS and cavernosus muscles' contraction. Sinusoidal muscle relaxation and contraction of cavernosus muscles upon distal urethral stimulation are suggested to be mediated through a reflex that we call the "urethro-corporocavernosal reflex." Sinusoidal and cavernosus muscles' response during coitus appears to effect a degree of tumescence for both male and female partners.

Electromyographic Study of the Anterolateral Abdominal Wall Muscles During Ejaculation

INTRODUCTION

The anterolateral abdominal wall muscles (AAWMs) are composed of the external and internal oblique, transversus abdominis, and the rectus abdominis muscles.

AIM

We investigated the hypothesis that the AAWMs contract reflexly during ejaculation.

METHODS

Effect of coitus on AAWMs was tested in 16 healthy men (mean age 37.2 +/- 9.7 years). The intra-abdominal pressure was measured by a manometric catheter introduced into the rectum. The response of the AAWMs to erection and ejaculation was recorded before and after penile and AAWMs' anesthetization by a needle electrode inserted into each of the muscles.

MAIN OUTCOME MEASURES

Electromyographic (EMG) activity of AAWMs and rectal pressure increased at ejaculation.

RESULTS

A few seconds before and during ejaculation, the rectal pressure and motor unit action potentials (EMG activity) of each of the AAWMs increased; this effect was abolished by anesthetization of the penis and AAWMs.

CONCLUSION

Increased AAWMs' EMG denotes contraction of the said muscles. AAWMs' contraction at ejaculation, the resulting increase of the intra-abdominal pressure, and the presumably increased pelvic venous congestion seem to augment the penile venous congestion and rigidity. This effect is suggested to be mediated through a reflex which we call "ejaculation-abdominal wall reflex."

The effect of external urethral sphincter contraction on the cavernosus muscles and its role in the sexual act

OBJECTIVES/AIM

A study of the effect of external urethral sphincter contraction on ischio-/bulbo-cavernosus muscles could not be traced in the literature. We investigated the hypothesis that external urethral sphincter contraction induces cavernosus muscles' contraction.

METHODS

Twenty-one healthy volunteers (age 37.6 +/- 9.7 SD years, 12 men, nine women) were studied. The electromyographic response of the ischio- and bulbo-cavernosus muscles to external urethral sphincter stimulation was recorded before and after anesthetization of the external urethral sphincter, and the ischio- and bulbo-cavernosus muscles; the response was also recorded using normal saline instead of lidocaine.

RESULTS

Upon external urethral sphincter stimulation (five square pulses, 1 ms duration, 53.8 +/- 10.2 mA threshold), both cavernosus muscles exhibited increased electromyographic activity with a mean amplitude of 386.2 +/- 44.9 microV for the ischio-cavernosus and 318.4 +/- 36.6 microV for the bulbo-cavernosus muscle. The mean latency read 16.8 +/- 1.3 ms for the ischio-cavernosus muscle and 15.7 +/- 1.2 ms for the bulbo-cavernosus muscle. Neither the ischio- nor the bulbo-cavernosus muscle responded to stimulation of the anesthetized external urethral sphincter, but both responded after saline administration. Likewise, the anesthetized ischio- and bulbo-cavernosus muscles showed no response to external urethral sphincter stimulation but responded after saline had been injected.

CONCLUSIONS

Increased electromyographic activity of the two cavernosus muscles on external urethral sphincter stimulation presumably denotes contraction of these two muscles and that this action is probably reflex, mediated through the 'sphinctero-cavernosus-reflex'. Cavernosus muscles' contraction assists in the erectile and ejaculatory mechanisms. It is suggested that this reflex be included as an investigative tool in the diagnosis of erectile and ejaculatory disorders, provided further studies are performed.

Physiological Considerations of the Morphologic Changes of the Testicles during Erection and Ejaculation: A Canine Study

<i>Purpose:</i> We investigated the hypothesis that testicles and scrotal skin undergo morphologic changes that would servethe mechanism of erection and ejaculation. <i>Materials and Methods:</i> Testicular and scrotal skin changes during erection and ejaculation were studied in 9 dogs. Testicular volume was measured by ultrasound, testicular temperature by digital thermometer and testicular vascularity by color duplex Doppler ultrasonography. Dartos muscle activity was studied by electromyography. <i>Results:</i> Testicular volume increased during erection and diminished at ejaculation. Testicular consistency became softer during erection and firmer at ejaculation. During erection and ejaculation the testicles were elevated closer to abdominal wall. Testicular temperature increased in the erectile phase followed by reduction during ejaculation. Doppler ultrasonography recorded increased testicular vascularity during erection and diminished vascularity at ejaculation. A dartos muscle electromyogram exhibited increased activity in the erectile and ejaculatory phases. <i>Conclusion:</i> During erection and ejaculation, testicles underwent changes which apparently serve the erectile and ejaculatory functions of penis.

Stress, Urge, and Mixed Types of Partial Fecal Incontinence: Pathogenesis, Clinical Presentation, and Treatment

The authors investigated the hypothesis that partial fecal incontinence (PFI) had variable manifestations that can be categorized as different types of PFI with different pathogeneses and treatment. Anal and rectal pressures as well as external and internal anal sphincter electromyographic activity were recorded in 163 patients with PFI and in 25 healthy volunteers. Patients were treated with biofeedback or surgically. Three types of PFI were encountered: stress fecal incontinence (SFI; 55 patients), urge fecal incontinence (UFI; 72 patients), and mixed fecal incontinence (MFI; 36 patients). Anal pressure decreased in three groups in which MFI had the lowest pressure. A significant reduction in external anal sphincter electromyographic activity occurred in SFI, in internal anal sphincter electromyographic activity in UFI, and of both sphincters in MFI. Bio-feedback cured 36 of 55 patients and postanal repair cured 10 of 19 patients with SFI. Forty-eight of 72 patients with UFI responded to biofeedback and 16 of 24 responded to internal anal sphincter repair. Biofeedback failed in MFI patients. Twenty-four of 27 patients who consented to operative correction of the sphincteric defect were cured. Three types of PFI could be identified: SFI, UFI, and MFI. Each type has its own etiology and symptoms, and requires individual treatment. Biofeedback succeeded in treating the majority of SFI and UFI patients. Surgical correction of the anal sphincter was performed after biofeedback failure.

Stress, urge, and mixed types of partial fecal incontinence: pathogenesis, clinical presentation, and treatment

The authors investigated the hypothesis that partial fecal incontinence (PFI) had variable manifestations that can be categorized as different types of PFI with different pathogeneses and treatment. Anal and rectal pressures as well as external and internal anal sphincter electromyographic activity were recorded in 163 patients with PFI and in 25 healthy volunteers. Patients were treated with biofeedback or surgically. Three types of PFI were encountered: stress fecal incontinence (SFI; 55 patients), urge fecal incontinence (UFI; 72 patients), and mixed fecal incontinence (MFI; 36 patients). Anal pressure decreased in three groups in which MFI had the lowest pressure. A significant reduction in external anal sphincter electromyographic activity occurred in SFI, in internal anal sphincter electromyographic activity in UFI, and of both sphincters in MFI. Biofeedback cured 36 of 55 patients and postanal repair cured 10 of 19 patients with SFI. Forty-eight of 72 patients with UFI responded to biofeedback and 16 of 24 responded to internal anal sphincter repair. Biofeedback failed in MFI patients. Twenty-four of 27 patients who consented to operative correction of the sphincteric defect were cured. Three types of PFI could be identified: SFI, UFI, and MFI. Each type has its own etiology and symptoms, and requires individual treatment. Biofeedback succeeded in treating the majority of SFI and UFI patients. Surgical correction of the anal sphincter was performed after biofeedback failure.

Cutaneous uretero-ureterostomy: a technique of urinary diversion for high-risk patients with bladder cancer

A simplified technique of cutaneous ureterostomy (CU) is presented for the treatment of high-risk bladder cancer patients. From 1968 to 2003, 2118 cystectomies with CU were performed for bladder cancer patients with uremic manifestations. The mean age was 67.4 +/- 27.3; 1206 patients were men and 912 were women. Cutaneous uretero-ureterostomy (CUU) was performed by three methods: (a) one ureter was brought across the midline and anastomosed end-to-side to the other ureter (end-to-side uretero-ureterostomy, ESUU); (b) the two ureters were placed side by side in a double-barrel fashion (double-barrel ureterostomy, DBU); or (c) the two distal ureteric ends were anastomosed together before fixation to the skin (side-to-side uretero-ureterostomy, SSUU). Selection of the technique depended on ureteric length and girth. No complications specific to CUU have occurred. Serum creatinine was normalized and intravenous pyelogram (IVP) showed improvement of obstructive manifestations and renal function. Ureterostomy stenosis was more common in ESUU than in DBU and SSUU; it responded to dilatation. This simple and easy procedure is shown to have a low rate of operative and postoperative complications and is indicated for high-risk patients with bladder cancer.

Mechanism of gastric emptying through the pyloric sphincter: a human study

BACKGROUND

The current view holds that gastric emptying is effected by the force of the antral peristaltic wave squeezing food particles through pyloric sphincter resistance. Whether this is accomplished by a reflex action was investigated.

MATERIAL/METHODS

The study comprised 12 healthy volunteers (age: 42.2+/-10.6 years). A balloon-tipped and a manometric tube were introduced into the stomach. Pressure responses in the proximal stomach, pyloric antrum, and pyloric sphincter to distension of the proximal stomach and of the antrum were recorded. Pyloric sphincter distension was induced to test its effect on antral and proximal stomach pressure. These tests were repeated in nine men after separately anesthetizing the pyloric antrum and sphincter.

RESULTS

Distension of the proximal stomach produced no pressure changes in the proximal stomach, pyloric antrum, or sphincter (p>0.05). Antral distension effected a significant rise in antral pressure, but not in the proximal stomach. Significant sphincter pressure decrease occurred only with antral distension volumes >50 ml. Pyloric sphincter distension produced a significant rise in antral pressure, but not in the proximal stomach. Sphincteric or antral anesthetization produced no pressure changes in the pyloric sphincter, antrum, or proximal stomach.

CONCLUSIONS

Pyloric sphincter relaxation upon antral distension implies a reflex relationship the authors call the "antro-sphincteric inhibitory reflex". Pyloric sphincter distension effected antral contraction, which is suggested to be a reflex in nature and which they term the "sphinctero-antral excitatory reflex". It is postulated that these two reflexes act to churn and transport gastric contents to the duodenum.

Role of sacral ligament clamp in the pudendal neuropathy (pudendal canal syndrome): results of clamp release

Pudendal canal syndrome (PCS) is treated by pudendal canal (PC) decompression. We studied the hypothesis that failure of PCD to relieve anal and perianal pain could result from compression of the pudendal nerve (PN) not only in the PC but also in the sacral ligament clamp (SLC), i.e., in the space between sacrotuberous and sacrospinous ligaments. SLC release was performed in 21 patients with proctalgia who had not improved after PCD. PN terminal motor latency was higher than normal. The SLC release operation comprised entering the ischiorectal fossa through a para-anal incision, identifying the PN, and division of sacrospinous ligament. Treatment was successful in 17 patients and failed in 4. The former showed pain disappearance and improvement in fecal incontinence, perianal sensation, and anal reflex. Clinical manifestations and investigative results improved after SLC release in 80.9% of the cases. We assume that these results denote traumatization of the PN not only in the PC but also in the SLC.

Physioanatomical relationship of the external anal sphincter to the bulbocavernosus muscle in the female

Both external anal sphincter (EAS) and bulbocavernosus muscle (BCM) have been shown anatomically and physiologically to constitute one muscle in males. We investigated the hypothesis that the EAS and BCM have similar anatomical pattern in females. The study consisted of cadaveric dissection, electromyographic recordings and inferior rectal nerve stimulation. Bulbocavernosus reflex action was performed in 16 healthy women before and after anesthetization of the EAS and BCM. The EAS extended forward across the perineal body and became continuous with the BCM in the labia majora. Glans clitoris (GC) or inferior rectal nerve stimulation effected synchronous EAS and BCM contractions with identical action potentials. GC stimulation while the EAS or BCM was anesthetized produced neither EAS nor BCM response. Similarly, stimulation of the anesthetized GC produced no EAS or BCM response. The BCM and EAS apparently constitute a single muscle, which seems to play dual and yet synchronous roles in fecal control and sexual response.

Corpora cavernosa as an alternative route for transfusion

Routine intravenous blood transfusion is difficult when the blood pressure falls significantly or veins are inaccessible or are sclerotic due to multiple transfusions. Here, we describe the use of penile corpora cavernosa (CC), as an alternative route for blood transfusion and fluid replacement. The study was conducted in 15 men, 7 with massive burns, 6 with sclerotic veins from repeated injections, and 2 with extensive limb trauma. After the conventional methods of blood and fluid infusions were exhausted, a needle was inserted into CC for blood and fluid administration. During blood or saline infusions, penile shaft became elongated but returned to a normal length after termination of the infusion. There were no difficulties during needle insertion into CC, in varying the different transfusion rates, or in repetition of transfusion during the same or the subsequent days. Complications were rare with the exception of a subcutaneous penile hematoma in 2 patients which disappeared spontaneously. Erection was not disturbed in five patients who were followed for a mean of 10.4+/-1.8 months. These findings show that corpora cavernosa can be used for blood transfusion or for administration of fluids as a simple, easy, rapid, and safe vascular access in conditions in which conventional routes are inaccessible.

Demonstration of a physiologic sphincter at duodeno-jejunal junction

Current evidence suggests that there are three sphincters that regulate the flow of chyme from stomach to the duodenum. We investigated the hypothesis whether a fourth 'physiologic sphincter' exists at the duodeno-jejunal junction. The pressure response of the jejunum, duodeno-jejunal junction and duodenum to individual balloon distension of the jejunum and duodenum was recorded in 28 healthy subjected before and after anesthesizing the jejunum, duodeno-jejunal junction and duodenum. The duodeno-jejunal junction length was measured by the station pull-through technique. Duodenal balloon distension with 2 and 4 ml of normal saline did not change the pressures in the duodenum, duodeno-jejunal junction or jejunum (p > 0.05). Distension with 6 ml saline produced an increase of duodenum pressure (p < 0.01), a decrease of duodeno-jejunal junction pressure (p < 0.01), and no change in the pressure of the jejunum (p > 0.05), the balloon was expelled to the jejunum. Eight, and 10 ml duodenum balloon distension produced pressure changes similar to those of the 6 ml distension (p > 0.05). Jejunum balloon distension with 2 and 4 ml saline induced no jejunum, duodeno-jejunal junction or duodenum pressure changes (p > 0.05). Six ml balloon distension effected increase of jejunum (p < 0.01) and duodeno-jejunal junction (p < 0.05) pressure, but no duodenum pressure changes (p > 0.05). Jejunum balloon distension with volumes more than 6 ml produced pressure changes similar to the 6 ml distension. Distension of the anesthetized duodenum, duodeno-jejunal junction or jejunum did not change the duodeno-jejunal junction pressure. A high pressure zone of 1.6+/-0.04 cm length was detected at the duodeno-jejunal junction. Together, the findings show that a high pressure zone exists at the duodeno-jejunal junction suggesting that this region might act as a physiological sphincter.

Detection of predefecatory rectosigmoid wave activity for prevention of fecal soiling in infants

Identification of an electrophysiologic sign before defecation can prevent fecal soiling in infants. To identify such a sign, the contractile activity of sigmoid colon was recorded percutaneously in 48 healthy infants. The recorder was equipped with a digital clock synchronized to the recorder so as to set off an alarm upon significantly increased electromyographic activity of sigmoid colon. Examination of the recordings at high speed revealed three types of basal, signaling and predefecatory waves of activities. The 'basal' component was comprised of as negatively deflected slow waves. The signaling waves exhibited an increase in amplitudes, cycle rate and conduction velocity, were repeated 8.2+/-1.2 times and lasted for 14.6+/-2.1 minutes prior to defecation, The 'predefecatory' waves preceded defecation by 40.3+/-7.3 seconds, showed a significant increase in wave parameters and sounded the alarm. The findings show a method for early detection of defecation that can be used clinically to prevent fecal soiling in infants.

Flaturia: passage of flatus at coitus. Incidence and pathogenesis

BACKGROUND/AIM

We present 18 women who under normal conditions had fecal and flatus control. They leaked flatus only during coitus. We investigated the hypothesis that these women had a concealed anal sphincteric disorder.

METHODS

Eighteen multiparous women (mean age 44.8+/-7.2 SD years) complained of involuntary passage of flatus during coitus of 4.6+/-2.4 years duration. Mean deliveries amounted to 8.2+/-2.1, of which 5.2+/-1.1 were by forceps. Patients had neither fecal nor flatus incontinence except during coitus. Nine healthy volunteers matching patients in age and number of deliveries but without coital passage of flatus were included in the study. Monitoring comprised anorectal pressure studies and external and internal anal sphincter (EAS, IAS) electromyography (EMG). Plain X-ray and barium enema studies were done to detect stools in the rectum.

RESULTS

The rectal and anal pressures at rest and on voluntary squeeze of the patients matched those of the healthy volunteers. The recto-anal inhibitory reflex (RAIR) in the patients was abnormal; it recorded on rectal contraction a significantly lower anal pressure than that of the healthy volunteers; also, the rectal contraction occurred at a volume lower than with the volunteers. The EAS EMG of patients was normal, while their IAS EMG recorded a significantly lower activity at rest and on rectal distension than those of volunteers. Stools were detected at rest in the rectum of all patients and in only two of the volunteers.

CONCLUSIONS

The distal end of the erect penis seems to buffet the lower rectum at coitus. In patients, the abnormal RAIR, the diminished IAS EMG as well as the presence of stools in the rectum at rest appear to be responsible for passage of flatus at coitus.

Interstitial cells of cajal in patients with constipation due to total colonic inertia

Colonic wall contains interstitial cells of Cajal. In view of studies demonstrating that Cajal cells generate electric waves which are presumably responsible for colonic motor activity, and that these waves are absent in total colonic inertia, we investigated the hypothesis that colonic Cajal cells might be disordered in patients with total colonic inertia. The study comprised 28 patients (age 41.6 +/- 8.2 SD years, 19 women, 9 men) with total colonic inertia in whom total colectomy was performed. Colonic specimens obtained from normal segments of the excised colon of 24 cancer patients acted as controls. Specimens were subjected to c-kit immunohistochemistry. Controls for antisera specificity consisted of tissue incubated with normal rabbit serum that had been substituted for the primary antiserum. C-kit-positive branched Cajal-like cells were detected in the musculature of the normal colonic segments. They were distinguishable from the C-kit-negative smooth muscle cells and the C-kit-positive but unbranched mast cells. No Cajal cells were detected in colon of total colonic inertia patients. The absence of Cajal cells in patients with total colonic inertia can be assumed to explain the absence of electric waves and motile activity previously reported in these patients. Further studies are needed to investigate the cause of Cajal-cell absence.

Cavernosus Muscle Contraction During Erection: Is It Voluntary or Reflex, Given the Striated Nature of the Muscles?

The bulbo- and ischio-cavernosus muscles (BCM, ICM) contract in the rigid erection phase, leading to a suprasystolic cavernosal pressure. We investigated the hypothesis that the contraction of cavernosal muscles is reflexogenic despite their striated nature. The intracavernosal pressure (ICP) and the cavernosus muscles' electromyography (EMG) were recorded in 18 healthy volunteers in the flaccid and erectile phases. The test was repeated after separate anesthetization of the cavernosus muscles and the corpora cavernosa while the penis was in the rigid erection phase. The ICM and BCM showed no EMG activity with tumescence and full erection. When the ICP reached a mean of 148.6 +/- 9.4 cm H2O, both the ICM and BCM showed increased EMG activity. The suprasystolic pressure was intermittent and corresponded to the intermittent BCM and ICM contraction. Voluntary cavernosus muscle contraction did not increase the ICP at the different stages of erection. Anesthetization of the penis in the rigid erection phase led to disappearance of the cavernosus muscles' EMG activity, while bland gel application did not. Anesthetization of the 2 contracting cavernosus muscles, while the penis was in the rigid phase, produced an ICP drop to 69.5 +/- 7.6 cm H2O; repetition with saline did not affect the ICP. Cavernosus muscle contraction on corporal pressure elevation seems to be reflex and mediated through the corporo-cavernosal reflex (CCR). Changes in the evoked response amplitude would indicate a defect in the reflex pathway.

Contractile activity of the prostate at ejaculation: An electrophysiologic study

OBJECTIVES

To investigate the hypothesis that the prostate contracts at ejaculation to push its secretions into the urethra. Although it has been mentioned that the prostate contracts at ejaculation, a report of this finding could not be traced in published studies.

METHODS

The electromyographic activity of 8 canine prostates was recorded by applying an electrode to the prostate. The prostatic urethral pressure was simultaneously measured by means of a manometric catheter. The prostatic electromyographic and urethral pressures were recorded at rest and on ejaculation by penile electrovibration.

RESULTS

The prostatic slow waves (SWs) and action potentials (APs), as well as the urethral pressure at rest, showed a significant increase during the ejaculatory bouts (P < 0.05 and P < 0.05, respectively). The SWs, APs, and pressure increase occurred simultaneously with each bout of ejaculatory spurt, which occurred at mean intervals of 1.1 +/- 0.02 seconds and a number of 4.6 +/- 1.2 bouts.

CONCLUSIONS

The electric waves discharged from the prostate at rest seemed to produce prostatic contractions, which cause prostatic urethral pressure increases. At ejaculation, the intermittent increase of the wave variables and urethral pressure coincided with the ejaculatory spurts, apparently denoting intermittent prostatic smooth muscle contractions. These contractions seem to squeeze the prostatic secretions into the prostatic urethra.

Vaginal and uterine pressure response to semen deposition into the vagina and uterus: human study

PURPOSE OF INVESTIGATION

The effect of semen deposition in the vagina or uterine cavity on both uterine and vaginal pressure has scarcely been reported in the literature. We investigated the hypothesis that semen deposition in the vagina or uterus effects changes in their pressure.

METHODS

The study comprised 27 healthy women volunteers (mean age 36.4 +/- 11.6 years). Both uterine and vaginal pressure were measured under basal conditions and on semen or saline deposition in the vagina and uterus.

RESULTS

Upon semen deposition in the vagina, the vaginal pressure showed no significant changes (p > 0.05) while the uterine pressure exhibited a significant intermittent rise (p < 0.05). Semen deposition into the uterine cavity caused no vaginal pressure changes (p > 0.05) while the uterine pressure exhibited an intermittent increase (p < 0.01). Saline injection into the vagina or uterus showed no significant pressure changes (p > 0.05).

CONCLUSION

Semen deposition into the vagina or uterine cavity was associated with uterine pressure elevation that might eventually help transport the sperm to the oviduct. Further studies are required to define the substances responsible for this effect.

Effect of straining on the muscles of the anterior abdominal wall. identification of the 'straining-adominal wall reflex'

The external and internal oblique, transverse abdominis and the rectus abdominis muscles constitute the anterolateral abdominal wall muscles. They are striated and contract voluntarily. We investigated the hypothesis that contraction of these muscles by coughing or straining, can also occur as a reflex. Effect of straining on muscles was tested in 19 healthy volunteers. The intra-abdominal pressure was measured by a manometric catheter introduced into the rectum. The response of the muscles to straining was recorded by a needle electrode inserted into each of the muscles. Similar to voluntary contractions, sudden and sustained straining produced increase in the rectal pressure and the motor unit action potentials of each of the muscles which was abolished by anesthesia. These findings suggest presence of a 'straining-abdominal wall reflex'.

Specialized pacemaking cells in the human Fallopian tube

It is postulated that the propagated electric activity of the gut is generated by the interstitial cells of Cajal (ICCs). We investigated the hypothesis of the presence of ICCs in the Fallopian tube (FT) as initiators of the tubal electric activity. Specimens from various parts of the FT were obtained from 21 female cadavers (mean age 38.2 +/-10.9 years) from the PostMortem Department of the Cairo University, Faculty of Medicine. Fixed sections were prepared and stained for c-kit. Controls for antisera specificity consisted of tissue incubated with normal rabbit serum substituted for the primary antiserum. Dendritic, c-kit-positive, ICC-like cells were detected in the tubal musculature of the studied specimens. They were distinguishable from the c-kit-positive nonbranching mast cells and from the c-kit-negative smooth muscle cells (SMC). Immunoreactivity was absent in the negative controls. We have for the first time identified cells in the FT with morphologic and immunologic phenotypes similar to the ICCs of the gut. These cells may be responsible for initiating the slow waves (SWs) recorded from the SMC of the FT. This is a preliminary study, and further studies are needed to investigate the functional role of these cells.

Conjoint corpora cavernosa and its role in erection

The two penile corpora cavernosa (CC) remain as separate structures along the penile shaft. During our study of 28 cadavers, we came across three cadavers in which the two CCs were fused together forming a single tubular structure; this article discusses these three cadaveric specimens. The cadavers were aged 52, 36, and 12 years. After penile degloving, the dorsal groove on the penile shaft was absent. In two of the cadavers, multiple transverse cut-sections in the penile shaft showed that the two CCs were united into one single tubular structure that extended from the symphysis pubis to the glans penis. The cut section was kidney-shaped, with the corpus spongiosum lying under cover of the concave surface. No intercavernosal septum was identified. The transverse cut-section of the third cadaveric specimen revealed an incomplete fusion of the two CCs. An intercavernosal septum was present in its upper part, but absent in its lower part where the two CCs were fused together. In all three cadaveric specimens, the CCs showed a normal histologic pattern and the corpus spongiosum was morphologically normal. Based on biomechanical principles, we theorize that the blood volume occupying the two CCs would be greater, the penile rigidity stronger, and the penetration force more powerful in the two separate CCs as normal than in the two CCs if fused. However, further studies involving large number of cases are needed.

Electromotor Activity of the Cecum and Ascending Colon: The Concept of ‘Individual Pacemakers’

BACKGROUND/AIMS

The cecum is described as differing anatomically from the ascending colon (AC); yet their similarity or difference in terms of motile activity has not been studied sufficiently. The cecum is separated from the AC by the cecocolonic junction (CCJ) which contains a cecocolonic sphincter. We assumed that the motile activity of the AC is different from that of the cecum and hypothesized that both the AC and the cecum might have different pacemakers which initiate the motile activity. This hypothesis was investigated in the current study.

METHODS

The study was performed in 10 subjects (mean age 41.6 +/- 12.8 SD years; 7 women) during the repair of huge abdominal incisional hernias. The electric activity was recorded from 2 monopolar electrodes applied each to the cecum, CCJ and AC. The CCJ was then anesthetized by xylocaine and the electric waves of the cecum, CCJ and AC were registered after 10 and 90 min. The test was repeated using normal saline instead of xylocaine.

RESULTS

Electric waves were recorded from the cecum, CCJ and AC in the form of monophasic pacesetter (PPs) and action potentials (APs). The PPs occurred regularly and the APs randomly. The frequency, amplitude and conduction velocity of the waves recorded from the CCJ and AC had higher readings than those from the cecum (p < 0.05). The CCJ and AC showed similar frequency and conduction velocity (p > 0.05). Ten minutes after CCJ anesthetization, electric waves were recorded from the cecum but not from the CCJ or AC; however, electric activity returned after 90 min. Saline injection did not affect the electric activity of the cecum, CCJ and AC.

CONCLUSION

The electric wave parameters of the cecum differed from those of the CCJ and AC, suggesting that the motile activity of the CCJ and AC is not a continuation of the motile activity of the cecum and that it might be evoked by 2 different pacemakers. The similarity in frequency and conduction velocity of electric waves of the CCJ and AC, however, most likely denotes that the AC waves are a continuation of those of the CCJ, and that both are evoked by the same pacemaker probably located in the CCJ. The higher amplitude of cecal waves might be due to the thicker cecal musculature compared to that of the AC.

Overactive bladder inhibition in response to pelvic floor muscle exercises

A recent study by the senior author demonstrated that striated urethral sphincter contraction effected the inhibition of vesical contraction and suppression of the desire to micturate, an action suggested to be mediated through the "voluntary urinary inhibition reflex". We hypothesized that the effect of pelvic floor muscle (PFM) exercises on the overactive bladder was mediated through this reflex action. The current communication investigates this hypothesis. A total of 28 patients (mean age 44.8+/-10.2 years, 18 men, 10 women) with overactive bladder and 17 healthy volunteers (mean age 42.6+/-9.8 years, 12 men, 5 women) were enrolled in the study. The vesical and posterior urethral pressures were determined before and after vesical filling reached the volume at which urge in control subjects, and involuntary voiding in the patients, occurred. Intra-abdominal pressure was recorded to obtain detrusor pressure readings. The bladder was refilled to the above volume and the subject asked to hold PFM contractions for 10 s during which the vesical and posterior urethral pressures were recorded. In healthy volunteers, the mean detrusor and posterior urethral pressures at urge to void were 30.6+/-4.8 SD and 18.7+/-3.3 cm H(2)O, respectively. On PFM contraction, the detrusor pressure declined to 11.6+/-1.4 cm H(2)O (P<0.01) and urethral pressure increased to 139.8+/-17.4 cm H(2)O (P<0.001). In patients, the mean detrusor and posterior urethral pressure readings when the bladder was filled to the volume which induced involuntary incontinence, were 28.2+/-4.2 and 17.3+/-3.4 cm H(2)O, respectively; on PFM contractions, the detrusor pressure decreased to 10.6+/-2.1 cm H(2)O (P<0.01), while urethral pressure increased to 86.6+/-7.9 cm H(2)O (P<0.001) and voiding did not occur. In conclusion, PFM contractions led to a decline of detrusor and increase of urethral pressures and suppressed the micturition reflex. These contractions appear to induce their effect by preventing internal sphincter relaxation produced by the micturition reflex. Failure of the internal sphincter to relax seems to cause reflex detrusor relaxation, an action presumably mediated through the "voluntary urinary inhibition reflex". The results of the current study encourage the treatment of overactive bladder with PFM contractions.