Established treatment options for male stress urinary incontinence

Nowadays, male stress urinary incontinence is rare and almost always of iatrogenic origin (radiotherapy, pelvic surgery). However, the prognosis of urinary incontinence following surgery is good and can be improved by pelvic floor muscle exercises in combination with biofeedback systems. For the remaining patient cohort with persistent urinary incontinence, several established surgical treatment options are available. Suburothelial injections of bulking agents can easily be performed in an ambulatory setting. However, regardless of the material used, long-term results are disappointing. Moreover, the residual urethral function deteriorates due to cicatrization of the suburothelial plexus with consequent loss of urethral elasticity.The fascial sling procedure in males has to be performed in preoperated areas and is as technically demanding for the surgeon as it is burdening for the patient. Alloplastic material is not used, thus minimizing risks for arrosion or infection. Since the sling tension can neither be standardized nor postoperatively readjusted, the risk of overcorrection is considerable and the success of the procedure is heavily dependent on the surgeon's experience. Despite wear and high revision rates, the technically mature artificial sphincter produces excellent continence results and has become the gold standard in the therapy of male stress urinary incontinence. The circumferential and continuous urethral compression by the cuff is highly effective, but at the price of an almost inevitable urethral atrophy. To overcome this problem, various surgical techniques have been developed (tandem cuff, cuff downsizing, transcorporal cuff placement). However, the expensive artificial sphincter is not a nostrum for every incontinent man, since it requires certain minimal cognitive and manual capabilities. Therefore, the search for less demanding treatment alternatives seems to be necessary, even if one has to accept lower continence rates.     

人工尿道括约肌治疗真性尿失禁

目的：探讨人工尿道括约肌治疗真性尿失禁的效果和安全性。方法：对1例前列腺电切术后尿失禁患者进行AMS800人工尿道括约肌植入治疗。记录植入术前术后的排尿日记，并观察不良反应。结果：施行人工尿道括约肌植入术后6周开通人工尿道括约肌，尿失禁得到良好地控制，恢复自主排尿，未发生并发症，无其他不良反应，结论：人工尿道括约肌植入术是一种安全有效的治疗真性尿失禁的方法。     

Long-term efficacy of AMS 800 artificial urinary sphincter in male patients with urodynamic stress incontinence due to spinal cord lesion

STUDY DESIGN: Retrospective analysis. OBJECTIVES: To evaluate long-term efficacy and complications of AMS 800 (American Medical Systems) artificial urinary sphincter (AUS) in treatment of urodynamic stress incontinence (USI) in male patients with spinal cord lesion (SCL). SETTING: London Spinal Injuries Unit, Stanmore, UK and Institute of Urology and Nephrology, London, UK. PATIENTS AND METHODS: A retrospective analysis identified nine males with SCL (five thoracic, three lumbar, one cervical) with USI, who underwent AMS 800 AUS implantation by a single surgeon at a specialist spinal injuries unit. The mean age was 38.2 years (range 27-47 years), with the mean time since injury of 13.8 years (range 6-26 years). In all, seven were complete and two were incomplete SCL (traumatic spinal injury eight, tranverse myelitis one). All implants were inserted with the urethral cuff around the bulbar urethra with a 61-70 cm water pressure reservoir in the retropubic space. Implant activation was carried out at 6 weeks postoperatively. All patients were regularly followed up in outpatient clinics at the interval of 3 months, 6 months and yearly thereafter. An ultrasound examination for the upper tracts and a video-cystometrogram (VCMG) was carried out at 3 months postsurgery and then yearly. RESULTS: The follow-up ranged from 3 to 133 months (mean 70.2 months). All implants were activated successfully with no intra- or immediate-postoperative complications. At activation all patients reported total urinary continence with seven out of nine implants (77%) currently working well. Two patients reported significant recurrent incontinence at 3 month follow-up, one of whom underwent a removal of the entire implant at the end of 3 months and the other was continent after a pump and cuff revision. The implant removed at 3 months was due to erosion and infection while the second was removed at 24 months due to secondary implant infection. Three out of seven (43%) successful implants required one revision each. One patient continues to report minimal leakage only during transfers with no leak demonstrated on postoperative VCMG. One patient with indwelling urethral catheter, two with suprapubic catheter and one voiding on urge have changed their bladder management to intermittent catheterisations postoperatively. All removals and revision procedures were carried out in the first 53 months of follow-up and four out of seven implants (57%) required no revisions. CONCLUSION: On a long term, AMS 800 is a viable option to treat USI in men with SCL. Mechanical revisions are frequent but effective. Strict patient selection, optimum preoperative bladder management and regular follow-up ensure low complication and high efficacy rates in the long term.     

The reproducibility of urodynamic studies of neurogenic bladders in spinal cord injury

OBJECTIVE: To evaluate the reproducibility (test-retest reliability) of urodynamic studies in neurogenic bladders of subjects with spinal cord injuries (SCI). DESIGN: Retrospective case series. SETTING: Urology department of a major rehabilitation center. SUBJECTS: Fifty individuals with SCI who had urodynamic studies performed from February 2000 to April 2000. MAIN OUTCOME MEASURES: Two trials (Time 1 and Time 2) of urodynamic studies done 5 minutes apart, with the following collected: bladder volume at first sensation, maximum cystometric capacity, presence of uninhibited contractions, opening pressure, maximum detrusor pressure, duration of bladder contraction, volume voided, and post-void residual (PVR) volume. The corresponding data were then compared. Statistical analysis was performed using the Lin's concordance correlation coefficient and kappa. RESULTS: Analysis of the data showed statistically significant levels of agreement between Time 1 and Time 2 with regard to the various corresponding parameters for both the filling and voiding phases. For 3 of the most important parameters-the opening pressure, maximum detrusor pressure, and duration of contraction-the Lin's concordance correlation coefficient (r(c)) was .86 (95% CI, .78-.95; p < .0005), .91 (95% CI, .86-.96; p < .0005), and .97 (95% CI, .95-.99, p < .0005), respectively. CONCLUSION: The study demonstrates good short-term intrasubject reproducibility of urodynamic studies in individuals with SCI.     

Change in urinary storage symptoms following treatment for female stress urinary incontinence

Introduction and hypothesis

Sling surgery is common for stress urinary incontinence (SUI). Yet many women have stress-predominant mixed urinary incontinence (MUI). The change in urgency/urge urinary incontinence (U/UUI) following treatment is not well documented. Our aim was to assess changes in U/UUI in women undergoing a sling placement for MUI and correlate this with improvement in quality of life (QOL).

Methods

This was a retrospective review of women treated for SUI with either an autologous rectus fascia pubovaginal sling (AF-PVS) or synthetic retropubic midurethral sling (MUS). Validated questionnaires—Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire–Short Form (IIQ-7), and visual analog scale (VAS) were obtained pre- and postoperatively. The independent association between change in storage symptoms and subjective cure—as defined by improved overall score on UDI-6, VAS score?≥?7, or both —were assessed using multivariate logistic regression.

Results

Nine hundred and twenty-seven women were identified for inclusion; 718 (77.5 %) had preoperative MUI, of whom 487 (67.8 %) received an MUS and 231 (32.2 %) an AF-PVS. Similar objective cure rates were noted following MUS vs. AF-PVS (78.2 % vs. 71.9 %, p?=?0.315). Subjectively, women treated with MUS experienced greater improvement in U/UUI (72.8 % vs. 57.6 %, p?=?<0.001) than AF-PVS. Multivariate analysis showed MUS patients were more than twice as likely to show subjective improvement in UDI-6 and VAS scores than the AF-PVS cohort. Postoperatively, validated questionnaires were significantly associated with storage symptom outcome.

Conclusions

Patients with U/UUI experience significant symptom improvement following treatment for MUI. QoL assessment following surgery is directly correlated with improvement in U/UUI.

     

The male reproductive function in patients with spinal cord injury

Seminal findings and blood hormone levels were studied for evaluating the male reproductive function in patients with spinal cord injury. The patients were divided into 3 groups, namely, 18 patients with complete injury, 5 patients with incomplete injury and 3 patients with dyspermatism. The number of sperms, the rate of movement and rate of deformation were measured for semen obtained by forced ejaculation. The number of sperms was kept at a relatively high level in the three groups, while the rate of movement fell off in all of the three groups. The rate of deformation was highest in the patients with complete injury and lowest in the patients with dyspermatism. As for blood hormone levels, LH, FSH and Testosterone (hereinafter referred to as TES) were determined by the RIA. The cases were classified into those in the acute stage and those in the chronic stage 3 months after sustaining injury for a comparative study. The subjects consisted of 27 cases in the acute stage and 47 cases in the chronic stage. For 8 patients in the acute stage, the blood hormone levels were determined even in the chronic stage and follow-up observations were made on the changes in the levels. The FSH level was low in both stages, while LH and TES tended to increase in the chronic stage. Particularly, the TES level was elevated in all the cases in the follow-up observations made in 8 patients. From the results mentioned above, transient disturbance of the interstitial function is suggested as the mechanism of male gonadal disturbance due to spinal cord injury.     

Clinical usefulness of the transobturator sub-urethral tape in the treatment of stress urinary incontinence in female patients with spinal cord lesion

Objectives

To evaluate the clinical usefulness of transobturator sub-urethral tapes for the treatment of stress urinary incontinence in women with spinal cord injury.

Method and subjects

Chart review for all female patients with spinal cord injury who underwent implantation of a transobturator sub-urethral tape for treatment of stress urinary incontinence at our institution.

Results

Nine women, median age 45.1 years, received a sub-urethral transobturator tape in the period November 2007 to September 2010. Four patients had paraplegia and five had tetraplegia. Seven women performed intermittent catheterization. At follow up, three of the nine patients were either cured or vastly improved. One major late complication (urethral erosion) occurred. Five of the six patients without treatment success underwent second-line treatment (artificial sphincter or urinary diversion).

Conclusion

In our case series, implantation of transobturator sub-urethral tapes in women with stress urinary continence due to intrinsic sphincter deficiency and a low leak point pressure led to unfavorable results.     

Clinical results of infertility treatment to male patients with spinal cord injury

It is difficult for male patients with spinal cord injury (SCI) to have children because of an ejaculation and dysfunction of spermatogenesis. However, owing to progress of assisted reproduction technology in recent years, it has become possible to have children even if the male has SCI, and the rate of success is improving gradually. During the 8 years from 1994 to 2002, infertility treatment was performed on 16 male patients with SCI consulting our hospital for acquistion of a child. We extracted their sperm by electroejaculation (EE) or testicular excision sperm extraction (TESE), and the sperm was artificially inseminated by the techniques such as artificial insemination with husband's semen (AIH), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI). Consequently, it was successful in 14 pregnancies on 10 couples, and resulted in 11 healthy live births on 7 couples. Four cases resulted in abortion. Two spouses are pregnant at present. There were no remarkable differences between the success group and the failure group in the quality of sperm such as concentration and motility. The mean age of the spouses who became pregnant was slightly lower than that of those who did not. Assisted reproduction techniques as EE and ICSI were useful techniques for patients with SCI wishing to have children.     

The treatment of stress urinary incontinence in women]

Fifty-six females with enuresis were observed in 1986-1990. Their x-ray examinations included urodynamic techniques: uroflowmetry, cystomanometry, test of the profile of the intraurethral pressure. Basing on the findings, 11 patients were excluded from the group to be operated on. Two kinds of surgery were employed: urethrovesicofixation according to Marshall-Marketti-Kranz, endoscopic submucous administration of teflon paste. The former method corrected the position of the bladder but is less effective in correction of the intraurethral pressure. The experience obtained by the authors permitted them to propose Marshall-Marketti-Kranz operation for apparent vesicoptosis whereas the teflon paste injection in enuresis without pronounced vesicoptosis. The methods can be used in combination: if, in spite of good anatomical results of the operation, enuresis persists, the paste administration is advocated to achieve better functional outcome.     

Use of polydimethylsiloxane for endoscopic treatment of neurogenic urinary incontinence in children

PURPOSE: We report on the injection of polydimethylsiloxane for endoscopic treatment of urinary incontinence in children with neurogenic bladder and determine the optimal criteria for patient selection. MATERIALS AND METHODS: We have treated 17 boys and 16 girls since 1995. The etiology of incontinence was spina bifida in 24 cases. Previous surgery was performed in 18 patients, including bladder neck reconstruction in 15 and bladder augmentation in 9. Mean patient age at injection was 13 years (range 7 to 17). We administered 1, 2 and 3 injections in 21, 11 and 1 patients, respectively. Mean volume at each injection was 3.2 cc. Mean interval between injections was 6 months (range 3 to 15). In all cases injection was done transurethrally. RESULTS: Followup ranged from 6 to 41 months (median 16). A total of 11 patients (33.3%) are dry (continence for greater than 4 hours and no urinary pad use during the day) and 8 (24.2%) are improved (continence for 2 to 3 hours and minimal pad use). Results are poor in 14 cases. Overall previous bladder neck surgery or preoperative detrusor hyperactivity did not influence results. Good results were mainly associated with female gender (47.4% of girls versus 10.5% of boys achieved cure). CONCLUSIONS: Injection of polydimethylsiloxane at the bladder neck resulted in continence in 33% of neurogenic bladder cases. Better results occurred in girls and injection did not compromise other surgical procedures. Polydimethylsiloxane seems more suitable than bovine collagen due to potential problems with biological product use.     

The risks of polypharmacy following spinal cord injury

Objective: The purpose of this study was to examine the overall prevalence of polypharmacy within the spinal cord injury (SCI) population, the level of polypharmacy with respect to seven classes of high-risk drugs commonly used to treat secondary conditions in the SCI population, and the overall risks for drug-related problems (DRP) related to polypharmacy.

Design: A retrospective case–control design.

Setting: A commercially available claims dataset that included patient cases from 4800 hospitals in the USA between 2007 and 2009.

Participants: Individuals with tetraplegia, paraplegia, and those with SCI but not specified as either tetraplegia or paraplegia as well as a control population of randomly selected, age- and sex-matched individuals without a diagnosis of SCI.

Outcome measures: The overall prevalence of polypharmacy, the prevalence of commonly prescribed high-risk medications, and the prevalence of reported DRPs.

Results: Overall, the patients in the SCI population were prescribed significantly more medications than their control counterparts. There was a higher rate of individuals being prescribed medications from multiple high-risk classes (e.g. analgesic-narcotics, anticonvulsant, antidepressant, and skeletal muscle relaxer), as well as multiple medications within each class (e.g. multiple analgesic-narcotics). The SCI group had a higher incidence of DRPs.

Conclusion: Our results are some of the first to demonstrate the extent of polypharmacy in individuals with SCI, including commonly prescribed high-risk medications, leading to a higher rate of DPRs. The higher rate of polypharmacy and DRPs can impact rehabilitation goals and community integration following neurologic injury.     

合理治疗脊髓损伤

在过去的30年中,我国脊柱脊髓损伤的治疗经历了从闭合复位、保守处理到积极手术治疗（包括开放复位、减压、内固定等）的过程。特别是近10年来脊柱外科的快速发展,为脊髓损伤的治疗带来了积极的影响。现根据我们迄今30年间救治脊柱脊髓损伤及施行康复治疗的经验,对合理治疗脊髓损伤的若干原则和方法进行探讨。