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Bianchi F, Squintani GM, Osio M, Morini A, Bana C, Ardolino G, Barbieri S, Bertolasi L, Caramelli R, Cogiamanian F, Currà A, de Scisciolo G, Foresti C, Frasca V, Frasson E, Inghilleri M, Maderna L, Motti L, Onesti E, Romano MC, Del Carro U. Neurophysiology of the pelvic floor in clinical practice: a systematic literature review. FUNCTIONAL NEUROLOGY 2018; 22:173-193. [PMID: 29306355 DOI: 10.11138/fneur/2017.32.4.173] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neurophysiological testing of the pelvic floor is recognized as an essential tool to identify pathophysiological mechanisms of pelvic floor disorders, support clinical diagnosis, and aid in therapeutic decisions. Nevertheless, the diagnostic value of these tests in specific neurological diseases of the pelvic floor is not completely clarified. Seeking to fill this gap, the members of the Neurophysiology of the Pelvic Floor Study Group of the Italian Clinical Neurophysiology Society performed a systematic review of the literature to gather available evidence for and against the utility of neurophysiological tests. Our findings confirm the utility of some tests in specific clinical conditions [e.g. concentric needle electromyography, evaluation of sacral reflexes and of pudendal somatosensory evoked potentials (pSEPs) in cauda equina and conus medullaris lesions, and evaluation of pSEPs and perineal sympathetic skin response in spinal cord lesions], and support their use in clinical practice. Other tests, particularly those not currently supported by high-level evidence, when employed in individual patients, should be evaluated in the overall clinical context, or otherwise used for research purposes.
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Abstract
OPINION STATEMENT Patients with progressive forms of multiple sclerosis have various symptoms which affect their quality of life significantly including depression, cognitive decline, sleep changes, bladder dysfunction, sexual dysfunction, and spasticity. Despite recent promising results on the effects of ocrelizumab on neurological disability in patients with PPMS, currently none of the immunomodulatory therapies are approved for progressive forms of multiple sclerosis. Therefore, clinicians currently mostly focus on management of well-recognized comorbidities of this disease phenotype in order to improve patients' quality of life. There are very few studies evaluating strategies of symptomatic management on progressive forms of multiple sclerosis and most of the data is derived from studies on relapsing forms of multiple sclerosis. Understanding of the risks, benefits, and limitations of these therapies can significantly affect patient care. In this article, we review common comorbidities associated with progressive forms of multiple sclerosis and outline important strategies for their symptomatic management.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter Sguigna
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stüve
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA. .,Neurology Section, VA North Texas Health Care System, Medical Service, Dallas, TX, USA.
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Pintér A, Cseh D, Sárközi A, Illigens BM, Siepmann T. Autonomic Dysregulation in Multiple Sclerosis. Int J Mol Sci 2015; 16:16920-52. [PMID: 26213927 PMCID: PMC4581177 DOI: 10.3390/ijms160816920] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 07/13/2015] [Accepted: 07/20/2015] [Indexed: 02/07/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, progressive central neurological disease characterized by inflammation and demyelination. In patients with MS, dysregulation of the autonomic nervous system may present with various clinical symptoms including sweating abnormalities, urinary dysfunction, orthostatic dysregulation, gastrointestinal symptoms, and sexual dysfunction. These autonomic disturbances reduce the quality of life of affected patients and constitute a clinical challenge to the physician due to variability of clinical presentation and inconsistent data on diagnosis and treatment. Early diagnosis and initiation of individualized interdisciplinary and multimodal strategies is beneficial in the management of autonomic dysfunction in MS. This review summarizes the current literature on the most prevalent aspects of autonomic dysfunction in MS and provides reference to underlying pathophysiological mechanisms as well as means of diagnosis and treatment.
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Affiliation(s)
- Alexandra Pintér
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden 01067, Germany.
| | - Domonkos Cseh
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
| | - Adrienn Sárközi
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
| | - Ben M Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Timo Siepmann
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden 01067, Germany.
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany.
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany.
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Lew-Starowicz M, Gianotten WL. Sexual dysfunction in patients with multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2015; 130:357-70. [DOI: 10.1016/b978-0-444-63247-0.00020-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Podnar S, Vodušek D. Place of perineal electrophysiologic testing in multiple sclerosis patients. Ann Phys Rehabil Med 2014; 57:288-296. [DOI: 10.1016/j.rehab.2014.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
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Prévinaire J, Lecourt G, Soler J, Denys P. Sexual disorders in men with multiple sclerosis: Evaluation and management. Ann Phys Rehabil Med 2014; 57:329-336. [DOI: 10.1016/j.rehab.2014.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
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Toosy A, Ciccarelli O, Thompson A. Symptomatic treatment and management of multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2014; 122:513-562. [PMID: 24507534 DOI: 10.1016/b978-0-444-52001-2.00023-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.
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Affiliation(s)
- Ahmed Toosy
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Olga Ciccarelli
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Alan Thompson
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK.
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Ghezzi A, Zaffaroni M, Baldini S, Zibetti A. Sexual dysfunction in male multiple sclerosis patients in relation to clinical findings. Eur J Neurol 2011. [DOI: 10.1111/j.1468-1331.1996.tb00250.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jiang J, He Y, Jiang R. Ultrastructural changes of penile cavernous tissue in multiple sclerotic rats. J Sex Med 2009; 6:2206-14. [PMID: 19453885 DOI: 10.1111/j.1743-6109.2009.01310.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is one of the important risk factors resulting in erectile dysfunction (ED). The ultrastructure of corpus cavernous of the penis have an important role in the mechanism of erection. AIM It is suggested that different medical conditions produce similar degenerative tissue responses. We investigated the ultrastructural changes of penile cavernous tissue and its association with ED in multiple sclerotic rats. METHODS After induction of multiple sclerosis in rat, maximum intracavernosal pressure/mean arterial pressure (ICP(max)/MAP) in the severity multiple sclerotic rats (group A),moderate multiple sclerotic rats (group C), and age-matched control rat (group B) were observed and compared. The ultrastructure of the penile cavernous tissue was studied by transmission electron microscope. Expression of neuronal nitric oxide synthase (nNOS) in penile tissue were examined immunohistochemically. MAIN OUTCOME MEASURES Severity MS (score 3) not only significantly decrease the ICPmax/MAP x 100 and the expression of nNOS, but also might affect the ultrastructure of the penis. RESULTS The ICP(max)/MAP x 100 in group A was significantly less than in group B and group C at 3 V (5.65 +/- 1.78, 20.49 +/- 5.84, and 12.78 +/- 5.76, respectively) and at 5 V (6.70 +/- 1.39, 23.66 +/- 5.19, and 16.95 +/- 3.31, respectively) stimulation voltage, respectively (P < 0.05). Significant ultrastructral pathological changes characterized by degeneration and demyelination singularly in Schwann cells without significant ultrastructural change of smooth muscle cells and endothelium cells were observed in penile cavernous tissue of group A rats. CONCLUSIONS The function of penile erection is affected by MS, and the ultrastructural pathological changes of the penile cavernous tissue may be one of the important mechanisms of ED caused by severity MS.
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Affiliation(s)
- Jun Jiang
- Affiliated Hospital, Luzhou Medical College, Department of Vascular Surgery, Luzhou, Sichuan, China
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Fletcher SG, Castro-Borrero W, Remington G, Treadaway K, Lemack GE, Frohman EM. Sexual dysfunction in patients with multiple sclerosis: a multidisciplinary approach to evaluation and management. ACTA ACUST UNITED AC 2009; 6:96-107. [DOI: 10.1038/ncpuro1298] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 12/15/2008] [Indexed: 11/09/2022]
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There remains a role for neurologic testing of patients with erectile dysfunction. CURRENT SEXUAL HEALTH REPORTS 2006. [DOI: 10.1007/s11930-006-0017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mann K, Sohn M. Spontaneous Nocturnal Erections - Physiology and Clinical Applications. Spontane nachtliche Erektionen - Physiologie und klinische Anwendungen. SOMNOLOGIE 2005. [DOI: 10.1111/j.1439-054x.2005.00057.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yang CC, Severson B, Bowen JD. Hypersexual sensations and behavior in a multiple sclerosis exacerbation: a case report. Int J Impot Res 2004; 16:382-4. [PMID: 15014553 DOI: 10.1038/sj.ijir.3901201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- C C Yang
- Department of Urology, University of Washington, Seattle, Washington 98195-6510, USA.
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Zivadinov R, Zorzon M, Locatelli L, Stival B, Monti F, Nasuelli D, Tommasi MA, Bratina A, Cazzato G. Sexual dysfunction in multiple sclerosis: a MRI, neurophysiological and urodynamic study. J Neurol Sci 2003; 210:73-6. [PMID: 12736092 DOI: 10.1016/s0022-510x(03)00025-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We studied 31 patients with relapsing-remitting (RR) multiple sclerosis (MS) in which we performed an urodynamic study, the pudendal cortical evoked potentials, the tibial cortical evoked potentials and the cranial and cervical spinal cord magnetic resonance imaging (MRI). We calculated the T(1) and T(2) lesion load (LL) and brain parenchymal fraction (BPF) of whole brain, frontal lobes, pons and cervical spinal cord. We also estimated the cross-sectional area at C(2) level. Spearman's rank correlation analysis showed a relationship between symptoms of sexual dysfunction and age (r=0.73, p<0.0001), cognitive performances (r=-0.63, p<0.0001), level of independence (r=-0.63, p<0.0001), disability (r=0.56, p<0.001), symptoms of anxiety (r=0.55, p<0.001) and depression (r=0.50, p<0.005), disease duration (r=0.42, p<0.02) and parenchymal atrophy in the pons (r=-0.38, p=0.031). Sexual dysfunction was not correlated with any other MRI measure, urodynamic patterns or cortical evoked potentials. In multiple regression analysis, sexual dysfunction was predicted only by T(1) lesion load of the pons. In conclusion, we confirmed previous correlations of sexual dysfunction with various clinical variables and demonstrated an association between sexual dysfunction and destructive lesions in the pons, as detected by MRI, in patients with relapsing-remitting multiple sclerosis.
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Affiliation(s)
- Robert Zivadinov
- Department of Clinical Medicine and Neurology, University of Trieste, Cattinara Hospital, Strada di Fiume, 447-34149 Trieste, Italy
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Abstract
Although patients with multiple sclerosis (MS) are likely to have problems with bladder, bowel and sexual function, these problems have often been neglected in the past. Bladder dysfunction produces symptoms of urgency, frequency and urge incontinence (due to bladder overactivity and incomplete emptying), and is found in up to 75% of patients with MS. The mainstay of drug treatment for neurogenic bladder overactivity is anticholinergic medication, although intravesical treatments have also been proposed, such as the vanilloids and botulinum toxin, as well as sublingual cannibanoids. There has been much progress with pro-erectile agents in recent years, notably the use of sildenafil citrate, which has been shown to be particularly efficacious in these patients. Other agents include apomorphine hydrochloride and newer phosphodiesterase 5 inhibitors; however, the efficacy of these drugs in patients with MS remains to be proven. Research in female sexual dysfunction is also progressing, although this aspect of patient well being has only recently been addressed; the reported development of a classification system for the condition is likely to help categorise future treatments. Unlike bladder and sexual dysfunction, there have been rather limited advances in the treatment of faecal incontinence and constipation specifically for patients with MS, despite a prevalence of up to 50%. This review highlights the strategies for these types dysfunction commonly seen in patients with MS, with report of recent pharmacological developments.
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Affiliation(s)
- Ranan DasGupta
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Abstract
Sildenafil citrate (Viagra) is a potent orally active cGMP-specific phosphodiesterase type 5 (PDE5) inhibitor that is effective as a peripheral conditioner in the treatment of male erectile dysfunction (ED) of organic, psychogenic or mixed aetiology. Sildenafil is the first effective oral agent in the management of ED that has had a revolutionary impact on management of ED. The present review has been subdivided into five major sections. Based on the most recent peer-reviewed publications, the first section is aimed at critically evaluating PDE5 selectivity as well as the pharmacokinetics and pharmacodynamics of the drug, mainly to assess the best doses for each group of patients (i.e. adult and elderly men). Effectiveness in a broad spectrum ED population is the subject of the second section of the review, principally reporting post-marketing company-independent results. Safety and tolerability are the key concerns of the third section, with a broad consideration of the most commonly reported adverse events. Special attention has been paid to the cardiovascular safety of the drug, chiefly outlining the positive and potentially protective cardiac effects of sildenafil. Moreover, the impact of sildenafil in special patient populations is considered, namely in men complaining of diabetes mellitus, depression, neurological disorders, renal failure and those who have undergone a radical prostatectomy. Sildenafil and the ageing male has been especially underlined. Finally, the review covers a few new potential applications of sildenafil in ED patients with regard to high-dose treatment and combination therapy. The review ends with several considerations regarding the direct and/or indirect impact of sildenafil over quality of life and quality of partnership.
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Affiliation(s)
- Andrea Salonia
- Department of Urology, University Vita-Salute San Raffaele, Milan, Italy
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DasGupta R, Fowler CJ. Sexual and urological dysfunction in multiple sclerosis: better understanding and improved therapies. Curr Opin Neurol 2002; 15:271-8. [PMID: 12045724 DOI: 10.1097/00019052-200206000-00008] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The fundamental strategy in treating multiple sclerosis patients with unstable bladders involves a combination of suppressing urgency and ensuring effective urinary drainage. Anti-cholinergics remain the first-line treatment, but alternative therapies are undergoing clinical trials. With a range of new pro-erectile oral medications available, interest has grown in treatment of multiple sclerosis-related erectile failure. Female sexual dysfunction is also now gaining some attention, with new classification criteria and methods for assessing and treating these patients.
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Affiliation(s)
- Ranan DasGupta
- Department of UroNeurology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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Affiliation(s)
- Elliot M Frohman
- UT Southwestern Medical Center at Dallas, Dallas, Texas 75390, USA
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Lundberg P, Ertekin C, Ghezzi A, Swash M, Vodusek D. Neurosexology. Guidelines for Neurologists. European Federation of Neurological Societies Task Force on Neurosexology*. Eur J Neurol 2001. [DOI: 10.1046/j.1468-1331.2001.0080s3002.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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CORTICAL EVOKED POTENTIALS OF THE DORSAL NERVE OF THE CLITORIS AND FEMALE SEXUAL DYSFUNCTION IN MULTIPLE SCLEROSIS. J Urol 2000. [DOI: 10.1097/00005392-200012000-00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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CORTICAL EVOKED POTENTIALS OF THE DORSAL NERVE OF THE CLITORIS AND FEMALE SEXUAL DYSFUNCTION IN MULTIPLE SCLEROSIS. J Urol 2000. [DOI: 10.1016/s0022-5347(05)66941-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Affiliation(s)
- SCOTT E. LITWILLER
- From the Departments of Urology and Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - ELLIOT M. FROHMAN
- From the Departments of Urology and Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - PHILIPPE E. ZIMMERN
- From the Departments of Urology and Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
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Affiliation(s)
- ARNOLD MELMAN
- Department of Urology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, and the Department of Urology, Southmead Hospital, Bristol, United Kingdom
| | - J. CLIVE GINGELL
- Department of Urology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, and the Department of Urology, Southmead Hospital, Bristol, United Kingdom
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Fowler CJ. The neurology of male sexual dysfunction and its investigation by clinical neurophysiological methods. BRITISH JOURNAL OF UROLOGY 1998; 81:785-95. [PMID: 9666759 DOI: 10.1046/j.1464-410x.1998.00640.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- C J Fowler
- Department of Uro-Neurology, National Hospital of Neurology and Neurosurgery, London, UK
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Stolp-Smith KA, Carter JL, Rohe DE, Knowland DP. Management of impairment, disability, and handicap due to multiple sclerosis. Mayo Clin Proc 1997; 72:1184-96. [PMID: 9413303 DOI: 10.4065/72.12.1184] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In this article, we update management measures for patients with multiple sclerosis (MS) that can improve or prevent impairment, disability, and handicap and include those factors that a primary-care physician can implement or facilitate. The medical literature since 1989 was reviewed. Although new drug trials hold promise to decrease impairment from MS, well-coordinated interdisciplinary care to minimize disability and handicap most profoundly affect the quality of life for patients with MS. MS is usually not severely disabling, and appropriately timed intervention can prevent secondary impairment and reduce disability and handicap. Pharmacologic, physical, and psychosocial issues--ranging from spasticity, pain, weakness, and tremor to neurogenic bowel management and sexuality--are addressed. General wellness measures remain important. The influence of the Americans With Disabilities Act is discussed, and specific adaptive equipment and social resources are outlined. The ultimate goals of management of patients with MS are functional independence and efficient use of medical and community resources: a focus on "ability" rather than "disability." Although impairment can limit function, wellness and adjustment have no boundaries.
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Affiliation(s)
- K A Stolp-Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Rochester, Minnesota 55905, USA
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