Urology & Multiple Sclerosis

Two hundred and twenty-five patients with Multiple Sclerosis and Bladder Dysfunction were evaluated. 72% had Urinary Incontinence, 46% Dysuria and 24% Urinary Retention.

Detrusor HyperReflexia was the most common finding on Cystometry (70%) and 9% of patients had Areflexia. Coaxial Needle Electromyography was performed on all patients and 82% had Detrusor-Sphincter DysSynergia.

Cortical Evoked Potentials following stimulation of the Pudendal Nerve were delayed in 72% and Sacral Evoked Latency in 16% especially in patients with Incontinence secondary to Overactive Bladder (25%), suggesting a Conus Medullaris lesion in these cases.

Urologic complications were noted in 40%, with Benign lesions in 24% (Diverticula, Urinary infections) and serious lesions in 16% (Hydronephrosis, Pyelonephritis, Renal Reflux).

The most common treatment was AntiCholinergic drugs (efficacy in 92%), AlphaBlocker agents (efficacy in 60%) and AutoCatheterism in 28%.

Objectives
The aim of this study was to assess frequency and importance of Urological complications in Multiple Sclerosis.

Methods
A total of 180 patients with Multiple Sclerosis (115 women, 64 men; mean disease duration 13.4 years) underwent the following examinations: NeuroPerineal Examination, Bladder And Kidney Echography, Intravenous Pyelography, Creatinine Assay, Urodynamic Investigation and Sphincter Electromyography.

Results
Detrusor HyperReflexia (70%) and Areflexia (15%) were the commonest findings on Cystometry and correlated with clinical data (Urinary Incontinence in 62% and Retention in 18%).

Urologic complications were noted in 56% with Benign lesions in 37% (Diverticula, Urinary infections) and serious lesions in 19% (Hydronephrosis, Pyelonephritis, Renal Reflux). No correlations were found between complications and DysSynergia, Overactivity and Urinary Retention.

Conclusions
The presence of these complications suggests the need for frequent Urodynamic and Radiologic controls in patients with Multiple Sclerosis.

Objectives
Multiple Sclerosis (MS) causes neurologic symptoms to change over time. Voiding dysfunction is common in patients with MS, and few studies have examined the changes in Urodynamic Patterns in these patients over time.

The purpose of this study was to examine the frequency and nature of Urodynamic Pattern changes in patients with MS who underwent two or more Urodynamic Studies.

Methods
Twenty-two patients (7 men and 15 women) with well-documented MS were referred to one Urologist (T.B.B.) for evaluation of lower Urinary Tract symptoms.

All patients had undergone two or more Urodynamic Evaluations during a 14-year period for persistent or new symptoms, and a retrospective comparison was made among the Urodynamic Test results.

Results
Overall, 12 (55%) of 22 patients experienced a change in their Urodynamic Patterns and/or compliance during a mean follow-up interval of 42 +/- 45 months between the Urodynamic Studies.

Most patients initially had Urodynamic Patterns showing Detrusor HyperReflexia, Detrusor external Sphincter DysSynergia, or Detrusor HypoContractility.

Fourteen (64%) of the 22 patients studied had the same or worsening of the same symptoms and 8 (36%) of 22 had new Urologic symptoms. Six (43%) of 14 patients with no new symptoms and 6 (75%) of 8 with new symptoms had significant changes found with follow-up Urodynamic Testing.

Conclusions
A significant proportion of patients with MS with and without new Urinary symptoms will develop changes in their underlying Urodynamic Patterns and Detrusor compliance.

Therefore, Urodynamic Evaluations should be repeated at regular intervals in symptomatic patients to optimize clinical management, reduce complications, and better enable these patients to manage their Neurogenic Bladder Dysfunction.

Aim
Bladder Dysfunction affects up to 90% of the Multiple Sclerosis (MS) population.

Interventions such as Pelvic Floor Training and Advice (PFTA), ElectroMyoGraphy (EMG) Biofeedback, and NeuroMuscular Electrical Stimulation (NMES) have received limited research attention within this population.

This study aimed to determine the effectiveness of a combined programme of PFTA, EMG Biofeedback, and NMES for Bladder Dysfunction in MS.

Methods
Females (n = 30) who fulfilled strict inclusion/exclusion criteria were recruited.

Outcome measures (weeks 0, 9, 16, and 24) included: 3-day Voiding Diary; 24 hr Pad-Test;

Uroflowmetry; Pelvic Floor Muscle Assessment;

Incontinence Impact Questionnaire (IIQ); Urogenital Distress Inventory (UDI);

King's Health Questionnaire (KHQ), and the Multiple Sclerosis Quality of Life-54 Instrument (MSQoL-54).

Following baseline (week 0) assessment, participants were randomly allocated, under double blind conditions, to one of the three groups:

Group 1 (PFTA); Group 2 (PFTA and EMG Biofeedback); and Group 3 (PFTA, EMG Biofeedback, and NMES). Treatment was for 9 weeks.

Results
Baseline severity (measured by number of leaks and pad weight) showed some variation between groups.

Although, not statistically significant (P > 0.05); with the caveat that this baseline imbalance makes interpretation difficult.

A picture emerges that at week 9, Group 3 demonstrated superior benefit as measured by the number of leaks and pad test than Group 2, with Group 1 showing less improvement when compared to week 0.

This was statistically significant between Groups 1 and 3 for number of leaks (P = 0.014) and pad tests (P = 0.001), and Groups 1 and 2 for pad tests (P = 0.001).

A similar pattern was evident for all other outcome measures.

Conclusion
Results suggest that these treatments, used in combination, may reduce urinary symptoms in MS. Further research will establish the effectiveness of these interventions.

Objective
Sacral Nerve NeuroModulation (SNS) is an effective treatment for Lower Urinary Tract Dysfunction. Many underlying Neurologic processes affect Lower Urinary Tract function.

We present results of SNS in patients with underlying Neurologic dysfunction.

Study Design
This is a retrospective case series of 33 patients with Neurologic Disease and Lower Urinary Tract Dysfunction who underwent an InterStim stimulation procedure.

Results were evaluated by pre- and postoperative voiding diaries. Success was defined as greater than 50% improvement.

Results
Twenty-eight of 33 patients (85%) underwent implantation: 13 of 16 (81%) Multiple Sclerosis, 4 Of 6 (67%) Parkinson Disease, and 11 of 11 (100%) other Neurologic Disorders.

Incontinence episodes per 24 hours decreased 68%, number of voids per 24 hours decreased 43%, Nocturia decreased 70%, and there was a 58% reduction in intermittent self-catheterization per 24 hours.

Ninety-three percent reported overall satisfaction.

Conclusion
Sacral nerve NeuroModulation is an effective treatment for Lower Urinary Tract Dysfunction in patients with underlying Neurologic Disease.

Aims
Transcutaneous Electrical Stimulation of the Dorsal Penile/Clitoral Nerve (DPN) has been shown to suppress Detrusor contractions in patients with Neurogenic Detrusor Overactivity (NDO).

However, the long-term use of surface electrodes in the genital region may not be well tolerated and may introduce hygienic challenges.

The aim of this study was to assess whether electrical stimulation of the Sacral Dermatomes could suppress Detrusor contractions in Multiple Sclerosis (MS) patients with NDO, hereby providing an alternative to DPN stimulation.

Materials And Methods
A total of 14 MS patients (8 M, 6 F) with low bladder capacity (< 300 ml) and a recent Urodynamic Study showing Detrusor Overactivity Incontinence participated in the study.

Three successive slow fill cystometries (16 ml/min) were carried out in each patient. The first filling served as control filling where no stimulation was applied.

In the second and third filling electrical stimulation of either the DPN or Sacral Dermatomes was applied automatically whenever the Detrusor pressure exceeded 10 cmH2O.

Results
The control filling showed Detrusor Overactivity in 12 of the 14 patients. In 10 of the 12 patients one or more Detrusor contractions could be suppressed with DPN stimulation.

Electrical stimulation of the sacral dermatomes failed to suppress Detrusor contractions in all patients.

Conclusions
Although therapeutic effects may be present from stimulation of the Sacral Dermatomes, we were unable to demonstrate any acute effects during Urodynamics.

For this reason stimulation of the Sacral Dermatomes is not an option in a system that relies on the acute suppression of a Detrusor contraction.

Copyright (c) 2007 Wiley-Liss, Inc.

Purpose
Of the various treatments proposed for Urge Incontinence, Frequency and Urgency ElectroStimulation has been widely tested.

Different techniques have been used with the necessity of surgical implantation (S3 NeuroModulation or Sacral Root Stimulation) or without requiring surgery (Perineal Transcutaneous ElectroStimulation).

Recently peripheral electrical stimulation of the Posterior Tibial Nerve was proposed for irritative symptoms in first intention or for intractable Incontinence.

Clinical studies have demonstrated good results and Urodynamic parameters were improved after chronic treatment.

However, to our knowledge no data concerning acute stimulation and immediate cystometry modifications have been reported. We verified Urodynamic changes during acute Posterior Tibial Nerve stimulation.

Materials And Methods
A total of 44 consecutive patients with Urge Incontinence, Frequency and Urgency secondary to Overactive Bladder were studied.

There were 29 women and 15 men with a mean age +/-SD of 53.3 +/- 18.2 years.

Of the patients 37 had Detrusor HyperReflexia due to Multiple Sclerosis (13), Spinal Cord Injury (15) or Parkinson's disease (9), and 7 had Idiopathic Detrusor Instability.

Routine cystometry at 50 ml. per minute was done to select the patients with involuntary Detrusor contractions appearing before 400 ml. maximum filling volume.

Repeat cystometry was performed immediately after the first study during left Posterior Tibial Nerve stimulation using a surface self-adhesive electrode on the ankle skin behind the internal malleolus with shocks in continuous mode at 10 Hz. frequency and 200 milliseconds wide.

Volume comparison was done at the first involuntary Detrusor contraction and at maximum cystometric capacity.

The test was considered positive if volume at the first involuntary Detrusor contraction and/or at maximum cystometric capacity increased 100 ml. or 50% during stimulation in compared with standard cystometry volumes.

Results
Mean first involuntary Detrusor contraction volume on standard cystometry was 162.9 +/- 96.4 ml. and it was 232.1 +/- 115.3 ml. during posterior tibial nerve stimulation.

Mean maximum cystometric capacity on standard cystometry was 221 +/- 129.5 ml. and it was 277.4 +/- 117.9 ml. during stimulation.

Posterior Tibial Nerve Stimulation was associated with significant improvement in first involuntary Detrusor contraction volume (p < 0.0001) and significant improvement in maximum cystometric capacity (p < 0.0001).

The test was considered positive in 22 of the 44 patients.

Conclusions
These results suggest an objective acute effect of Posterior Tibial Nerve Stimulation on Urodynamic parameters.

Improved bladder overactivity is an encouraging argument to propose Posterior Tibial Nerve Stimulation as a noninvasive treatment modality in clinical practice.

Objective
To determine whether Transcutaneous Electrical Nerve Stimulation (TENS) benefits patients with Urinary symptoms caused by Neurological Diseases.

Patients And Methods
Patients with Urinary symptoms from any kind of Neurological disease were prospectively recruited between October 1996 and July 1998.

Before attending the first assessment patients were asked to complete a week's diary recording the frequency of micturition, Incontinence episodes, and frequency of pad and clothes changing.

At the first assessment the patients completed the Frimodt-Moller urinary symptom questionnaire, and quality-of-life scales including the Nottingham Health Profile and Short-Form 36.

Demographic and disability data (Barthel Index and Frenchay Aphasia Screening Test) were recorded, and patients underwent a Neurological Examination and Urodynamic studies.

The placing of electrode pads on the sacral dermatomes 2.5 cm either side of and 2.5 cm above the natal cleft was demonstrated, and the patient instructed to use TENS for 90 min twice a day.

The current strength applied was set to that which the patient could tolerate, at a square-wave of 20 Hz and 200-micros duration.

Six weeks later the patients were further assessed, where the diary exercise, questionnaires and Urodynamics were repeated. In all, 44 patients (13 men and 33 women, mean age 50.8 years) were recruited.

Results
The commonest disease was Multiple Sclerosis and the commonest impairments para/tetraplegia or hemiplegia. There was no change in the Neurological status of the 34 patients completing the study.

Irritative voiding symptoms were significantly decreased (0.68-0.61, P = 0.003) and diaries also showed significant improvements in the 24 h frequency of Micturition (P = 0.01), Incontinence episodes (P = 0.04) and clothes changes (P = 0.02).

Urodynamics showed Detrusor Hyper-Reflexia in most patients.

The only significant changes after TENS were an increased postvoid residual volume (from a mean of 134 mL to 160 mL, P = 0.03) and an increase in the volume leaked during the Urodynamic study with TENS on (from a mean of 4.7 mL to 12 mL, P = 0.003).

There were no significant changes in the quality-of-life scores. Of the 34 patients completing the study, half still reported a benefit from TENS at 1 year, although some patients found it took 3-4 weeks to work.

Conclusion
TENS applied to the sacral Dermatomes of Neurological patients with Urinary symptoms had a minimal effect on Urodynamic data.

But, significantly improved irritative Urinary symptoms, 24-h Urinary frequency, Incontinence and clothes changing.

The lack of effect on quality-of-life measures probably reflects the lack of sensitivity in the tools used in this group of patients. We therefore recommend using TENS in this often problematical group of patients.

Purpose
We assess clinical and Urodynamic results of Sacral Nerve Stimulation for patients with Neurogenic (Spinal Cord Diseases) Urge Incontinence and Detrusor HyperReflexia resistant to ParaSympatholytic drugs.

Materials And Methods
Since 1992, 9 women with a mean age of 42.6 years (range 26 to 53) were treated for refractory Neurogenic Urge Incontinence with Sacral Nerve stimulation.

Neurological Spinal Diseases included Viral and Vascular Myelitis in 1 patient each, Multiple Sclerosis in 5 and traumatic Spinal Cord Injury in 2.

Mean time since Neurological diagnosis was 12 years. All patients had Incontinence with chronic pad use related to Detrusor HyperReflexia.

Intermittent self-catheterization for external Detrusor-Sphincter DysSynergia was used by 5 patients. Social life was impaired and these patients were candidates for Bladder augmentation.

A Sacral (S3) lead was surgically implanted and connected to a subcutaneous NeuroStimulator after a positive test stimulation trial.

Results
Mean followup was 43.6 months (range 7 to 72). All patients had clinically significant improvement of Incontinence, and 5 were completely dry. Average number of voids per day decreased from 16.1 to 8.2.

Urodynamic parameters at 6 months after implant improved significantly from baseline, including maximum Bladder capacity from 244 to 377 ml. and volume at first uninhibited contraction from 214 to 340 ml.

Maximum Detrusor pressure at first uninhibited contraction increased in 3, stabilized in 2 and decreased in 4 patients. Urodynamic results returned to baseline when stimulation was inactivated.

All patients subjectively reported improved visual analog scale results by at least 75% at last followup.