Sexual disorders post-stroke: Description of a cohort of patients followed in rehabilitation

INTRODUCTION

The impairments resulting from a stroke can be multiple, including urinary and/or sexual dysfunctions. This acquired brain injury disrupts neurological control of sexual responses.

MAIN OBJECTIVE

to describe sexual disorders, after a first episode of stroke, in a population followed in a physical medicine and rehabilitation (PMR) center.

SECONDARY OBJECTIVES

to gather patients' expectations and PMR physicians' opinions on this subject.

METHOD

Observational, retrospective study in two PRM centers. Post-stroke sexuality was assessed using two validated questionnaires [for men: International Index of Erectile Function 15 (IIEF15) and for women: Female Sexual function Index (FSFI)]. Patients were asked 3 questions to approximate their expectations, and PRM physicians were asked 2 questions for their opinions.

RESULTS

Twenty-four subjects included (17 men/7 women). Thirteen had no post-stroke sexuality. Erectile function was analysable in 4 subjects, 3 of whom had moderate to severe erectile dysfunction. In women, female sexual dysfunction concerned 6/7 women, including lubrication. Ninety-six percent of subjects had never discussed sexuality with their PRM physician. Only 33% would have liked information on this subject. Our PRM physicians rarely discuss post-stroke sexual disability.

CONCLUSION

Post-stroke sexual disorders occur in both sexes. All areas of sexuality may be affected. A large-scale, prospective, controlled, multicenter study is needed to establish stroke as the direct neurological cause of sexual impairment.

[Is there any obstruction other than prostatic obstruction in Idiopathic Parkinson's Disease?]

OBJECTIVE

To highlight the existence of pseudo-dyssynergia in Idiopathic Parkinson's Disease (IPD) constituting a functional bladder outlet obstruction.

MATERIALS AND METHODS

A retrospective study was conducted by including men with a confirmed diagnose of IPD who participated in the SIROCCO rehabilitation program. Patients included clinically exhibited overactive bladder and voiding dysfunction without prostatic hypertrophy ultrasounded. They have been clinically assessed by the Urinary Symptoms Profile (USP) urinary symptom score. Bladder outlet obstruction was assessed by the pressure-flow study. Urodynamic obstruction has been quantified by the bladder obstruction index which depends on detrusor pressure at maximum flow rate and maximum flow rate. It has been defined by a BOOI>40.

RESULTS

The pressure-flow profile was analyzed in 5 patients who met the inclusion criteria. In this group of 5 patients with IPD, the diagnosis was made on average 10.6 years (7-14) before the pressure-flow studies were performed. Our results objectified 4 patients obstructive among 5 and one equivocal patient. A striated pseudo-dyssynergia was found in the 3 obstructive patients and associated with a smooth pseudodyssynergia in one patient.

CONCLUSION

We have observed, in this short series, a pseudo-dyssynergia by subjects suffering from IPD.

LEVEL OF EVIDENCE

3.

Ejaculation and sperm characteristics in men with cauda equina and conus medullaris syndromes

STUDY DESIGN

Retrospective.

OBJECTIVES

The objective of the study was to describe the type of ejaculation in patients with cauda equina (CE) and conus medullaris (CM) lesions, and to analyse sperm quality.

SETTING

France.

METHODS

One hundred sixty-six patients with CE and CM lesions were included. Diagnosis was based on clinical (no motor responses, sensation or sacral reflexes) and urodynamic assessments (no detrusor activity). Vibromassage (VM) was used to induce ejaculation according to the recommendations for patients with spinal cord injury. If ejaculation did not occur, oral midodrine was administered in progressive doses. Retrograde ejaculation was systematically sought. Sperm parameters were analysed according to World Health Organisation recommendations (2010).

RESULTS

Eighty-nine patients were included. Eleven ejaculated on the first VM trial (four anterograde (AE), six retrograde (RE) and one antero-retrograde (ARE)). Five patients continued trials of VM alone, two of whom ejaculated following a mean 1.9 trials (one RE, one ARE). Twenty-six patients underwent trials of VM+ midodrine, 18 of whom ejaculated following a mean 4.4 trials with a mean dose of 22.5 g of midodrine (2 AE, 13 RE and 5 ARE). Fifty-three ejaculates from 26 patients were analysed. Sperm concentration was low in 90.6% of samples; total necrospermia was found in 65% and asthenospermia in 95% of samples.

CONCLUSION

Ejaculation is difficult to induce using VM in patients with CE and CM lesions, and requires high doses of midodrine. Sperm counts were generally low, and asthenospermia and necrospermia were found in the majority of specimens. Cryopreservation of sperm should be systematic in case of medically assisted procreation.

Predictors of outcome for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia in men with spinal cord injury

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

The objective of this study was to determine outcome predictors for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury.

METHODS

Botulinum toxin type A (100 Units Botox, Allergan) was injected into the external urethral sphincter using a transperineal approach under EMG guidance. Treatment was indicated if DSD was found on urodynamic testing with a post-void residual volume (PVR) above 100 ml. Urodynamic tests and cystourethrograms were performed at baseline. Dysuria (scale of 1-5) and PVR (48- h bladder diary) were evaluated at baseline and 1 month. The outcome was deemed excellent when PVR was equal to or <100 ml and 20%, and dysuria rated <3.

RESULTS

Seventy-two men with tetraplegia and 27 with paraplegia were included. There were significant reductions in PVR (from 227 to 97 ml and 63% to 27%) and dysuria (from 4.3 to 2.3). Excellent outcomes were found in 48 patients (48%), and the duration of effectiveness was 6.5 months. The need for catheterisation was decreased or eliminated in 18 patients. Vesicoureteral reflux disappeared in some patients. Poor outcome was significantly related to the presence of bladder neck dyssynergia and the absence of detrusor contraction in standard cystometry. Outcome was also related to the severity of DSD, with a strong correlation between PVR before and after injection (r=0.58). Injections were repeated in 36 patients and yielded similar outcomes in most cases (89%).

CONCLUSIONS

Detrusor contractions (odds ratio=8.6) and normal bladder neck activity (odds ratio=7.1) are strong predictors of excellent outcome.

Are oxybutynin and trospium efficacious in the treatment of detrusor overactivity in spinal cord injury patients?

OBJECTIVES

To evaluate the efficacy of anticholinergic agents in the treatment of neurogenic overactive bladder (NOAB) and neurogenic detrusor overactivity (NDO) in spinal cord injury (SCI) patients on clean intermittent catheterisation (CIC).

METHODS

Chronic suprasacral SCI patients on CIC presenting with at least one urinary leakage a day were included. Urodynamics and voiding diaries were performed at baseline and 1 month follow-up. In case of NDO at baseline, an anticholinergic drug was prescribed.

RESULTS

The 231 SCI patients presented with one to five urinary leakages per day (mean 2.1). Urodynamics showed NDO in all patients. A new anticholinergic treatment was started in all, either in monotherapy (134 patients) or in association with the existing anticholinergic drug (oxybutynin+trospium bitherapy, 97 patients). The mean maximum bladder capacity significantly increased from 225 to 441 ml, and the mean involuntary detrusor contractions (IDC) significantly decreased from 67 to 41 cm H2O. Only 75 SCI patients (32%) were fully continent. However, 25 out of these 75 patients showed persistent NDO, with amplitudes of IDC above 40 cm H2O in 12 patients. Incontinence was still found in 156 SCI patients (67%), with an average of 1,2 leakages a day. In 100 patients, amplitudes of IDC remained above 40 cm H2O. There was no statistical difference between patients on anticholinergic monotherapy or bitherapy at follow-up.

CONCLUSION

Anticholinergic treatment is not always satisfactory in terms of control of NDO and rarely allows full continence. Urodynamic follow-up is mandatory in all patients, even in those showing clinical continence.

[Multifocal bony hemangioendothelioma: a case report]

Hemangioendothelioma is a rare tumor (0.5% of primary malignant bone tumors) generally found in long bones and tarsal bones. We report a case in a 67-year-old man who underwent surgery in 1987 for a tumor of the left ankle. He again consulted in 1998 for pain in the left knee. Standard x-rays of the left lower limb evidenced multiple partitioned bone defects with cortical lysis in the femoral condyle, the upper and lower portions of the tibia and the talus. Computed tomography showed a lytic image of the lower femoral and superior tibial epiphysis without cortical or soft tissue involvement. Laboratory findings were normal. Pathology examination of a biopsy specimen led to the diagnosis of grade I multifocal bony hemangioendothelioma of the medial femoral condyle and the medial upper tibial facet of the left knee. Search for extension was negative. Curettage followed by cement filling of all tumor sites and postoperative radiotherapy were successful. No recurrence has been observed 3 years later. The histological polymorphism of hemangioendotheliomas leads to varying therapeutic management schemes.