Analysis of the upper urinary tract function in multiple sclerosis patients

Aims –  The objective of this study was to analyse the upper urinary tract (UT) function in a group of consecutive multiple sclerosis (MS) patients, who had not previously been treated by urologist.
Materials and methods –  Ninety-two MS patients suffering from lower UT dysfunction were included in the study. The group of patients consisted of 69 women and 23 men. The average Expanded Disability Status Scale (EDSS) score in our group was 4.29 (0–8.5). Functional examination of the kidneys using assessment of creatinine clearance and morphological examination of the kidneys using ultrasound was performed in all patients. Analysis of the upper UT function is presented.
Results –  The average serum creatinine clearance in our group was 132.84 ml/min/1.73 m² (46.8–510). Lower levels than normal were found in three patients (3.3%). Abnormal ultrasound findings were recorded in five patients (5.4%). The creatinine clearance was correlated with the clinical subtype of MS, the severity expressed by EDSS, the urodynamic parameters, the duration of the disease, the duration of the symptoms of lower UT and the EDSS score. We did not find a statistically significant correlation for any of these parameters.
Conclusions –  Our results suggest that impairment of the upper UT function is exceptional in MS patients.     

Evaluation of the urinary tract in children with myelomeningocele

Of 43 children suffering from myelomeningocele, 2 died of obstructive nephropathy; 30 survived for more than 6 years and 12 of these developed upper urinary tract dilatation. A bladder compliance above 20 was only found in 4 patients, while in 11 with detrusor hyperreflexia, a low pressure amplitude was generally observed. Detrusor-sphincter dyssynergia accompanied by large residual volumes was found in 4 patients. Surveillance of the urological condition is discussed.     

Pneumonia and urinary tract infection after acute ischaemic stroke: a tertiary analysis of the GAIN International trial.

The third most common stroke complication is infection. We studied the rates of aspiration pneumonia and urinary tract infection (UTI), their risk factors and their effect on outcome in the 1455 Glycine Antagonist (Gavestinel) in Neuroprotection (GAIN) International patients with ischaemic stroke. Forward stepwise logistic regression and Cox proportional hazards modelling identified baseline factors that predicted events and the independent effect of events up to day 7 on poor stroke outcome at 3 months in patients alive at day 7, after correcting for prognostic factors. Higher baseline National Institute of Health Stroke Scale (NIHSS) and age, male gender, history of diabetes and stroke subtype predicted pneumonia, which occurred in 13.6% of patients. Female gender and higher baseline NIHSS and age predicted UTI, which occurred in 17.2% of patients. Pneumonia was associated with poor outcome by mortality (hazard ratio, 2.2; 95% confidence interval, 1.5-3.3), Barthel index (<60) (odds ratio, 3.8; 2.2-6.7), NIHSS (4.9; 1.7-14) and Rankin scale (>/=2) (3.4; 1.4-8.3). UTI was associated with Barthel index (1.9; 1.2-2.9), NIHSS (2.2; 1.2-4.0) and Rankin scale (3.1; 1.6-4.9). Pneumonia and UTI are independently associated with stroke poor outcome. Patients with identified risk factors must be closely monitored for infection.     

Topographic representation of lower and upper teeth within the trigeminal sensory nuclei of adult cat as demonstrated by the transganglionic transport of horseradish peroxidase

Transganglionic transport of horseradish peroxidase-wheat germ agglutinin conjugate (HRP-WGA) entrapped in hypoallergenic polyacrylamide gel was used to study the patterns of termination of primary afferents that innervate the lower and upper tooth pulps within the trigeminal sensory nuclear complex (TSNC). HRP injections were made into the inferior and superior alveolar nerves in order to compare the central projections of the whole nerve with those from tooth pulps. In addition, the relationship between the distribution of the trigeminothalamic tract cells and the projection sites of the tooth pulp afferents was investigated by injecting HRP into the posterior ventral thalamus. HRP-labeled tooth pulp afferent fibers innervating the lower and upper teeth projected to the subnucleus dorsalis (Vpd) of pars principalis, the rostrodorsomedial part (Vo.r) and nucleus dorsomedialis (Vo.dm) of pars oralis, the medial regions of pars interpolaris, and laminae I, II, and V of pars caudalis. Terminal fields of the lower tooth pulp afferents formed a rostrocaudally running, uninterrupted column from the midlevel of Vpd to the caudal tip of caudalis. In contrast, the column of termination of upper tooth pulp afferents was discontinuous at the Vpd/Vo.r transition, and ended at the more rostral level of the caudalis than that of the lower tooth pulp afferents. The representation of the lower and upper teeth in the TSNC was organized in a somatotopic fashion which varied from one subdivision to the next, although terminal zones of the inferior and superior alveolar nerves overlapped within the Vo.r, Vo.dm, and dorsomedial part of rostral pars interpolaris. The lower and upper teeth were represented in the Vpd, Vo.r, Vo.dm, medial region of pars interpolaris, and laminae I, II, and V, in a ventrodorsal or caudorostral, dorsoventral, lateromedial, dorsoventral, and mediolateral or dorsomedial-ventrolateral sequence, respectively. The smaller, more focal terminal areas of the teeth contrasted sharply with more extensive terminal fields of the alveolar nerves. The HRP injections within the thalamus indicated that neurons in Vpd, the caudal pars interpolaris, and laminae I/V of caudalis, which are subdivisions of TSNC that receive pulpal projections, sent their axons to the ipsilateral and contralateral posterior ventral thalamus.(ABSTRACT TRUNCATED AT 400 WORDS)     

The effect of glutamate antagonists on c-fos expression induced in spinal neurons by irritation of the lower urinary tract

Chemical irritation of the lower urinary tract (LUT) of the rat increases the expression of c-fos in neurons in the dorsal horn, dorsal commissure and intermediolateral region of the spinal cord. The role of glutamatergic synapses in this response was examined using two glutamate receptor antagonists, MK-801 (an NMDA antagonist) and CNQX (an AMPA antagonist). In rats with an intact spinal cord, MK-801 (3.5 mg/kg, i.v.) administered 15 min before bladder irritation decreased (50–60%) the number of c-fos-positive cells in all regions of the cord. A smaller dose of MK-801 (0.8 mg/kg, i.v.) was ineffective. In spinal transected rats (4–7 days prior to the experiment) MK-801 (3.5 mg/kg, i.v.) decreased c-fos expression only in the medial dorsal horn. CNQX (1.2 mg/kg, i.v.) was ineffective in both preparations. These results indicate that activation of NMDA receptors at glutamate synapses in the central nervous system may play a role in the processing of nociceptive input from the LUT and may also be involved in reflex pathways mediating micturition.     

Central connections of the lingual-tonsillar branch of the glossopharyngeal nerve and the superior laryngeal nerve in lamb

Afferent and efferent central connections of the lingual-tonsillar branch of the glossopharyngeal nerve (LT-IX) and the superior laryngeal nerve (SLN) in the lamb were traced with horseradish peroxidase (HRP) histochemistry. After entering the brainstem, most LT-IX and SLN afferent fibers turned caudally in the solitary tract (ST). Some afferent fibers of LT-IX terminated in the medial nucleus of the solitary tract slightly caudal to their level of entry. The remaining fibers projected to the dorsolateral, ventrolateral, and interstitial areas of the nucleus of the solitary tract (NST) at the level of the area postrema. Superior laryngeal nerve afferent fibers terminated extensively in the medial and ventral NST at levels near the rostral pole of the area postrema. Further caudal, near the level of obex, SLN afferent terminations were concentrated in the region ventrolateral to the ST and in the interstitial NST. The caudal extent of LT-IX and the rostral extent of SLN terminals projected to similar levels of the NST, but only a relatively small proportion of the total projections overlapped. Lingual-tonsillar and SLN fibers also coursed rostrally to terminate in the caudal pons within and medial to the dorsomedial principal sensory trigeminal nucleus. Other labeled afferent fibers traveled caudally in the dorsal spinal trigeminal tract to terminate in the dorsal two-thirds of the spinal trigeminal nucleus at the level of obex. Large numbers of labeled cells with fibers in the LT-IX or SLN were located in the ipsilateral rostral nucleus ambiguus and surrounding reticular formation. Fewer labeled cells were observed in the inferior salivatory nucleus following HRP application to either the LT-IX or SLN. The LT-IX and SLN projections to areas of the NST associated with upper airway functions, like swallowing and respiration, suggest an important role for these two nerves in the initiation and control of airway reflexes.     

Changes in galanin immunoreactivity in rat lumbosacral spinal cord and dorsal root ganglia after spinal cord injury

Alterations in the expression of the neuropeptide galanin were examined in micturition reflex pathways 6 weeks after complete spinal cord transection (T8). In control animals, galanin expression was present in specific regions of the gray matter in the rostral lumbar and caudal lumbosacral spinal cord, including: (1) the dorsal commissure; (2) the superficial dorsal horn; (3) the regions of the intermediolateral cell column (L1-L2) and the sacral parasympathetic nucleus (L6-S1); and (4) the lateral collateral pathway in lumbosacral spinal segments. Densitometry analysis demonstrated significant increases (P < or = 0.001) in galanin immunoreactivity (IR) in these regions of the S1 spinal cord after spinal cord injury (SCI). Changes in galanin-IR were not observed at the L4-L6 segments except for an increase in galanin-IR in the dorsal commissure in the L4 segment. In contrast, decreases in galanin-IR were observed in the L1 segment. The number of galanin-IR cells increased (P < or = 0.001) in the L1 and S1 dorsal root ganglia (DRG) after SCI. In all DRG examined (L1, L2, L6, and S1), the percentage of bladder afferent cells expressing galanin-IR significantly increased (4-19-fold) after chronic SCI. In contrast, galanin expression in nerve fibers in the urinary bladder detrusor and urothelium was decreased or eliminated after SCI. Expression of the neurotrophic factors nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) was altered in the spinal cord after SCI. A significant increase in BDNF expression was present in spinal cord segments after SCI. In contrast, NGF expression was only increased in the spinal segments adjacent and rostral to the transection site (T7-T8), whereas spinal segments (T13-L1; L6-S1), distal to the transection site exhibited decreased NGF expression. Changes in galanin expression in micturition pathways after SCI may be mediated by changing neurotrophic factor expression, particularly BDNF. These changes may contribute to urinary bladder dysfunction after SCI.     

Different expressions of α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid and N-methyl-D-aspartate receptor subunit mRNAs between visceromotor and somatomotor neurons of the rat lumbosacral spinal cord

The glutamatergic transmission system plays a key role in afferent and efferent pathways involved in micturition. By in situ hybridization combined with retrograde Fast Blue labeling, expression of α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptor (GluR-A to -D) and N-methyl-D -aspartate (NMDA) receptor (NR1 and NR2A-D) subunit mRNAs were examined in visceromotor and somatomotor neurons of the rat lumbosacral spinal cord. Parasympathetic preganglionic neurons (PGNs) in the intermediolateral nucleus highly expressed GluR-A and GluR-B subunit mRNAs, with very low levels for GluR-C and GluR-D subunits. As for the NMDA receptor, PGNs were associated with abundant signals for NR1 subunit mRNA, but without any NR2 subunit mRNAs. On the other hand, somatomotor neurons in the ventral horn (dorsolateral nucleus) express all four AMPA receptor subunit mRNAs, showing relatively abundant expressions of GluR-C and GluR-D subunit mRNA compared with PGNs. In addition to high levels of NR1 subunit mRNA, dorsolateral nucleus neurons moderately expressed NR2A and NR2B subunit mRNAs. These results suggest that molecular organization of both AMPA and NMDA receptor channels are distinct between PGNs and dorsolateral nucleus neurons. Considering that native NMDA receptors are heteromeric channels composed of NR1 and NR2 subunits, it seems likely that dorsolateral nucleus neurons, not PGNs, are provided with functional NMDA receptors, which could induce activity-dependent changes in synaptic transmission in the efferent pathway for the lower urinary tract. J. Comp. Neurol. 404:172–182, 1999. © 1999 Wiley-Liss, Inc.     

卒中急性期下尿路功能障碍与焦虑障碍相关性研究

目的 探讨卒中后下尿路功能障碍与焦虑障碍之间的关系,并通过病变部位及膀胱尿动力学方法探 讨其相关联系。 方法 据第4届全国脑血管学术会议修订诊断标准筛选卒中患者,据梗死部位分组,入院后行焦虑 自评量表（Sel f-rating Anxiety Scale,SAS）评分,记录其排尿日志,对焦虑障碍与排尿障碍的发生相关 性进行分析,并统计额叶损伤患者的发病率。 结果 额叶卒中组比非额叶组卒中后下尿路功能障碍（lower urinary tract dysfunction,LUTD）发生率 高约1.75倍,额叶卒中组比非额叶组卒中后焦虑障碍（post-stroke anxiety disorder,PSAD）发生率高约 2.16倍。尿动力检查提示：LUTD伴焦虑障碍者膀胱活动度明显增高。 结论 卒中后焦虑障碍及排尿障碍较为常见,且额叶卒中的发生率更高,以储尿期排尿障碍为主。 患者的排尿异常与其高级脑功能、日常生活能力、卒中后情绪等因素相关。尿流动力学改变多为逼尿 肌过度活动,但症状与尿流动力学表现不完全一致,必要时应做此检查以利于进一步治疗。     

Post-stroke lower urinary system dysfunction and its relation with functional and mental status: a multicenter cross-sectional study

Background: Review of the literature clearly reveals that little is known about the association between functional and mental status, and Lower Urinary Tract Dysfunction (LUTD) in patients with stroke.

Objective: The aim of this study was to assess functional and mental status in stroke patients and to identify possible associations with the prevalence, severity and bother of LUTD.

Material and methods: This study was designed as a cross-sectional study and included 260 stroke patients enrolled from six different hospitals in Turkey. The patients were questioned using the Danish Prostatic Symptom Score (DAN-PSS) Questionnaire to evaluate LUTD, and evaluated using the Modified Barthel Index (MBI), Incontinence Quality of Life Questionnaire (I-QoL), and the Mini Mental State Examination (MMSE).

Results: At least one LUTD finding was reported in 243 (93.5%) patients; the most commonly encountered complaint in these patients was nocturia (75.8%). The mean MBI, MMSE, and I-QoL scores were found to be significantly lower in LUTD (+) patients compared to LUTD (?) patients (p = 0.000, p = 0.005, and p < 0.01, respectively). Similarly all parameters (MBI, MMSE, and I-QoL scores) assessed were found to be significantly lower for patients with urinary incontinence than those without incontinence (p = 0.000, p = 0.000, and p < 0.01, respectively).

Conclusion: LUTD is a common problem in patients with stroke. LUTD is associated with poorer cognitive and functional status and the quality of life in these patients. We, therefore, suggest that bladder dysfunction should not be overlooked during rehabilitation of stroke patients.     

Urinary dysfunction and autonomic control in amyloid neuropathy

Abstract Uro-neurological assessment was performed in four patients with small-fiber neuropathy due to amyloidosis (2 transthyretin-type/2 immunoglobulin light-chain-type). Voiding difficulties were due to detrusor weakness and impaired bladder sensation. In two patients cholinesterase inhibition treatment caused urge incontinence, indicating detrusor denervation supersensitivity. The underlying mechanisms of urinary dysfunction seem to involve postganglionic cholinergic and afferent somatic nerves.