In multiple sclerosis, a Functional Independence Measure ≥ 107 is the best predictor of outcome after clean intermittent catheterization training

BACKGROUND

Assessment of motor and cognitive functions is recommended before clean intermittent catheterization training. Two validated instruments, the Functional Independence Measure (FIM) and the Pencil and Paper Test (PP-Test), are associated with the ability to learn self-catheterization in people with multiple sclerosis.

OBJECTIVES

We aimed to compare the performance of these tools in predicting the outcome of clean intermittent catheterization training in multiple sclerosis.

METHODS

All people with multiple sclerosis attending a tertiary neuro-urology department between 2011 and 2019 and eligible for clean intermittent catheterization were included in this retrospective study. The reference standard was the ability to perform at least 2 trials of self-catheterization at the end of the training session. The 2 index tests, the FIM and PP-Test, were administered before the teaching session. Their diagnostic performance was estimated by calculating sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). The AUC values were compared by a two-sided DeLong test.

RESULTS

We included 395 individuals (mean [SD] age 49.8 [12] years; 70% women). At the end of the session, 87% of the patients succeeded in learning self-catheterization. The optimal cut-offs for the FIM (107) and PP-Test (13) were estimated, resulting in sensitivity of 73% (95% confidence interval [68-77) and 73% (67-77) and specificity 73% (59-84) and 63% (49-76), respectively. The AUC values for the FIM and PP-Test were significantly different (0.79 vs 0.73, p = 0.049). The effect size was large for both the FIM (Cohen's d = 1.14) and PP-Test (Cohen's d = 0.87).

CONCLUSIONS

An FIM value ≥107 has the best specificity to predict outcome after clean intermittent catheterization training for people with multiple sclerosis. The sensitivity of the FIM and PP-Test is similar, and both have a large effect size for the outcome of self-catheterization training in multiple sclerosis.

French version of the short form of neurogenic bladder symptom score: Cross-cultural adaptation and validation

Introduction: This study aimed to empirically validate a French version of the Neurogenic Bladder Symptoms Score-Short From (NBSS-SF), a psychometric multidimensional tool to assess lower urinary tract symptoms (LUTS) for patients with a neurological condition. Methods: One hundred and five participants with multiple sclerosis or spinal cord injury prospectively completed the questionnaire at baseline and 7–14 days later. The α coefficient of Cronbach (internal consistency) and the intraclass correlation coefficient (ICC) (test-retest reliability) were calculated. Results: The internal consistency for the overall questionnaire was high (Cronbach’s α coefficients from 0.79), while coefficients for each subscale were variable (urinary incontinence 0.91; storage and voiding 0.69; consequences 0.25). For test-retest reliability, 88/105 (84%) patients filled and sent back their questionnaire 10 days (±3.6 days) after baseline version. ICC was 0.90 for the total score and was 0.73 for the urinary incontinence subdomain, 0.79 for storage and voiding, and 0.75 for consequences. Conclusions: The psychometric qualities of the French version of the NBSS-SF are well-supported, thus providing a valid tool to measure bladder symptoms across three different domains in patients with a neurogenic bladder.

Cortical, Spinal, Sacral, and Peripheral Neuromodulations as Therapeutic Approaches for the Treatment of Lower Urinary Tract Symptoms in Multiple Sclerosis Patients: A Review

INTRODUCTION

Multiple sclerosis (MS) is often associated with urological disorders, mainly urinary incontinence and retention, the management of which being necessary to improve patient's quality of life (QOL) and to reduce potential urological complications. Besides the classical treatments based mainly on anticholinergics and/or self-catheterization, several neuromodulation techniques have been tried in recent years to improve these urinary disorders. By this review, we aim at providing an overview of neuromodulation and electrostimulation approaches to manage urinary symptoms in MS patients.

MATERIALS AND METHODS

A literature search using MEDLINE was performed. Only papers in English, and describing the effects of neuromodulation in MS patients, were considered.

RESULTS

A total of 18 studies met inclusion criteria and were reviewed. Of them, four related to sacral neuromodulation (SNM), seven to percutaneous tibial nerve stimulation (PTNS), six to spinal cord stimulation (SCS), and one to transcranial magnetic stimulation (TMS).

DISCUSSION

PTNS and SNM seem to be effective and safe therapeutic options for treating lower urinary tract symptoms in MS patients principally in case of overactive bladder (OAB) symptoms. Similarly, also SCS and TMS have been shown to be effective, despite the very limited number of patients and the small number of studies found in the literature. Interestingly, these techniques are effective even in patients who do not respond well to conservative therapies, such as anticholinergics. Furthermore, given their safety and efficacy, stimulations such as PTNS could be considered as a first-line treatment for OAB in MS patients, also considering that they are often preferred by patients to other commonly used treatments.

Determinants and impact of the time to perform clean intermittent self-catheterization on patient adherence and quality of life: A prospective observational study

AIMS

To measure the time required to perform clean intermittent self-catheterization (CISC) in daily life and to assess its impact on adherence and quality of life.

METHODS

Patients performing CISC for more than 1 month were invited to participate. At home, patients were asked to complete a 1-day diary to assess the specific duration of the CISC (time from when the equipment and environment are brought together to perform CISC) and the next day to complete a second diary for the total duration of the CISC (starting when the patient intent to self-catheterize to the return to the initial activity, including the displacement, and gathering the required device). Adherence, difficulties with CISC, and quality of life were measured with validated questionnaires: Intermittent Catheterization Satisfaction Questionnaire, Intermittent Catheterization Difficulty Questionnaire, Intermittent Catheterization Adherence Scale, and SF Qualiveen Questionnaire.

RESULTS

Thirty-six patients agreed to participate but only 25 patients completed the entire protocol. The participants performed CISC for an average of 7 years. The median specific duration of CISC was 2 min and 23 s (ranging from 47'' to 11'50''). The median total duration of CISC was 3 min and 40 s (1'35''; 18'47''). No significant correlation was found between the duration of CISC and patient characteristics, adherence, difficulty to self-catheterize, or quality of life.

CONCLUSION

The time to perform CISC was brief, and less than 2-3 min on average. The impact on adherence and quality of life should be assessed in a larger cohort.

[Neurological complications of coitus: Review of literature]

INTRODUCTION

Sexual activity is composed of different phases (excitation, plateau, resolution). Each phase is associated with cardiovascular, respiratory, muscular and hormonal modification which can have an influence on the nervous system. This impact has been studied many times in literature, but no study has synthetized the complications related to coitus or orgasm.

METHOD

Systematic review of literature on neurological complications, except headache, of coitus based on Medline and Embase.

RESULTS

We screened 1424 articles and selected 46 for this review. 7 (15 %) were clinical or epidemiologic studies, 6 (13 %) were reviews of literature and 33 (72 %) were cases or series of cases reports. 12 articles (26 %) talked about strokes, 10 (22 %) about subarachnoid hemorrhage, 9 (20 %) about reversible cerebral vasoconstriction syndrome. We found 3 (7 %) articles for each of the following complication: intraparenchymal, hematoma and epilepsy. Autonomic hypereflexia was treated in 3 articles (7 %). Only 1 article was included concerning ictus, spinal cord injury, neuralgia and cataplexia. These events can be considered as rare as emergencies related to sexual activity represent only 0.1 % of all emergencies and among these, 12 % are neurological. 31 of the reported cases concerned vascular events (stroke or hemorrhage) and 18 (58 %) of these patients had a patent malformation (aneurism, intracardiac shunt, foramen ovale).

CONCLUSION

This is one of the first review of literature trying to synthetise the neurological complications of coitus. Many articles exist in literature. It is necessary to prevent the occurrence of these complications in a population already at risk of neurological events.

External Anal Sphincter Fatigability: An Electromyographic and Manometric Study in Patients With Anorectal Disorders

Background/Aims

External anal sphincter (EAS) plays an important role in fecal and gas voluntary continence. Like every muscle, it can be affected by repeated efforts due to fatigability (physiological response) and/or fatigue (pathological response). No standardized fatiguing protocol and measure method to assess EAS fatigability has existed. The aim is to test a simple, standardized protocol for fatiguing and measuring EAS fatigability and fatigue to understand better the part of EAS fatigability in the pathophysiology of fecal incontinence.

Methods

Patients with anorectal disorders evaluated with anorectal manometry were included. They had to perform 10 repetitions of maximum voluntary contraction (MVC) of 20 seconds. Measurement was made with an anorectal manometry catheter and a surface recording electromyography (EMG). The primary outcome was the difference in EMG root mean square between the first and the last MVC. Secondary outcomes were differences in other EMG and manometry parameters between the first and the last MVC. Difficulties and adverse effects were recorded.

Results

Nineteen patients underwent the fatiguing protocol. All patients completed the entire protocol and no complications were found. No difficulty was declared by the examiner. A significant decrease in root mean square was found between the first and last MVC (0.01020 ± 0.00834 mV vs 0.00661 ± 0.00587 mV; P = 0.002), in maximum anal pressure area under the curve of continuous recordings of anal pressure and mean and total EMG power (P < 0.05).

Conclusions

This protocol is simple and minimally invasive to measure EAS fatigue and fatigability. We highlighted a fatigue of EAS in many patients with anorectal disorders.

[Urethral reflexes: A review]

INTRODUCTION

The urethrosphincter complex is involved not only in maintaining urinary continence, particularly during effort, but also for the achievement of a complete and effective micturition. Indeed, the urethra is not a simple passive channel for the evacuation of urine from the bladder to the urethral meatus, since its resistive capacities and its possibilities of modulation of the micturition reflex depend on its reflex role either as a sensory afferent or as a neuro-muscular effector. It also participates in many genito-sexual and ano-rectal réflexes.

MATERIAL AND METHOD

This review of the literature describes the various reflexes of the urethra as a sensory stimulus or a neuromuscular effector. All articles referenced in this review were obtained from articles indexed on Pubmed-Medline, using the keywords: "urethral reflexes; "reflex bladder"; "urination reflex"; "intravaginal; vaginal"; "anorectal; sphincter"; "Storage and voiding"; "reflexes sneezing"; "cough reflex". Other articles were selected through references of the articles issued from the first research. Only articles in English and French have been selected. The articles concerned animal and human experiments.

RESULTS

Eight hundred and sixty-four referenced articles were founded and a total of 75 articles were included, describing the various reflexes mediated by the urethra acting as a sensory afferent or mechanical effector. We differentiated the known data in humans and animals.

CONCLUSION

The urethra is a complex anatomical structure ensuring, through numerous reflex mechanisms, urinary continence. Urethral resistances are modulated during efforts and depends on the bladder capacity and the intensity of the efforts. During micturition, the coordination between the bladder and the urethra is mediated by reflex pathways organized at the cerebral, spinal and lumbosacral levels. The modulation of the micturition in term of efficacy and velocity, is due in part, to the re-afferentation of the spinal reflex by continuous stimulus of the urethral canal. Many of these reflexes are imperfectly described. Finally, the urethra is implicated in reflex loops of anal continence and sexual functions.

Relationship between desire to void and bladder capacity and rectal sensory function in patients with multiple sclerosis and anorectal disorders

AIMS

The primary aim of this study was to assess the relationship between a strong desire to void (SDV) and rectal sensory function in patients with multiple sclerosis (PwMS) and anorectal disorders. The secondary aim was to identify clinical, urodynamic or manometric factors associated with greater rectal sensory function impairment in this population.

METHODS

Thirty PwMS (mean age 49.2 ± 10.9 years) with anorectal disorders (constipation and/or fecal incontinence) participated in this observational study. Rectal sensory parameters during anorectal manometry were recorded at a strong desire to void and after urination (PV, post-void). The primary outcome was the desire to defecate volume. Secondary outcomes were first perception and maximum tolerated threshold volumes, presence and modulation of recto-anal inhibitory reflex.

RESULTS

The mean desire to defecate volume was 125 ± 59 mL at SDV and 104 ± 64 mL at PV (P < .001). The mean maximum tolerated volume was 167 ± 61 mL at SDV vs 141 ± 64 mL after urination (P = .01). The other parameters were not different between SVD and PV conditions. No predictive factors for greater impairment of rectal sensory function were identified.

CONCLUSION

This study suggests a relationship between bladder sensation and thus bladder capacity, and rectal sensory function in PwMS and with anorectal disorders.

[Urinary disorders of Wolfram syndrome. Clinical and urodynamic analysis from 6 observations]

Wolfram syndrome is a neurodegenerative disorder characterized by childhood onset diabetes mellitus, optic nerve atrophy, diabetes insipidus, hearing impairment, brainstem alteration and commonly bladder and bowel dysfunction.

OBJECTIVE

We present here, 6 new cases of urinary dysfunction in this rare disease.

RESULTS

All patients had urinary retention with overactive bladder. The urodynamic assessment found overactive detrusor in 3 cases. Five out of six patients performed self-catheterization and were treated with anticholinergics or intradetrusor injection of botulinum toxin. The follow-up at 5 years found an alteration of the upper urinary tracts and a renal failure 3/6.

CONCLUSION

Urinary dysfunction is common in Wolfram syndrome, mainly characterized by overactive bladder and urinary retention. The urological risk is major requiring a systelmatic follow-up of these patients.

LEVEL OF EVIDENCE

4.