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Background Provoked vestibulodynia is a relatively common condition that affects sexual activity. Multidisciplinary care is indicated and OnabotulinumtoxinA injections are safe and effective treatment in this indication. Aims To assess the long-term efficacy of OnabotulinumtoxinA in provoked vestibulodynia. Materials and methods Twenty-one patients treated with OnabotulinumtoxinA injections (50U in each bulbospongiosus muscle) 24 months prior to the study were included. Data on pain [assessed using a visual analogue scale (VAS)], quality of life [measured by the Dermatology Life Quality Index (DLQI)] and quality of sex life [assessed using the Female Sexual Function Index (FSFI)] were collected before treatment, and 3 and 24 months after injection. Results Nineteen patients participated in the study and 37% had no pain after 24 months. Significant improvements were noted in the VAS, DLQI and FSFI scores between baseline and 24 months post treatment (P < 0.0001). After 24 months, 18 patients (95%) were able to have sexual intercourse. This study was open and non-controlled. Discussion and conclusion 100U OnabotulinumtoxinA injections constitute an effective treatment in provoked vestibulodynia with results maintained after 2 years. They significantly improve pain, and have a positive impact on patient quality of life and sex life. Beneficial effects continue in the long-term, allowing patients to resume sexual activity. more...

Resume Introduction Le but de ce travail etait de faire une revue de la litterature sur l’evaluation clinique et paraclinique de la sensibilite vesicale (SV) afin de mieux apprehender les troubles de la SV chez les patients non neurologiques. Methode Trente-trois articles ont ete selectionnes a partir de Medline® Database entre 1992 et 2012. Les mots cles etaient « sensory/sensitivity bladder evaluation », « sensory/sensitivity bladder scale », « sensory/sensitivity bladder questionnaire », « urodynamic bladder sensory », « urgency questionnaire » et « OverActive Bladder (OAB) questionnaire ». Les articles traitant des douleurs vesicales et d’atteintes neurologiques ont ete exclus. Resultats L’evaluation de la SV par questionnement lors de la cystomanometrie est validee (NP 2). La progression du besoin evolue de facon lineaire avec le remplissage vesical (NP 2). De nombreux questionnaires de symptomes et de qualite de vie associes a une anomalie de la SV ont ete proposes. Des calendriers mictionnels, des courbes frequence/volume (NP 2) et des algorithmes cliniques (NP 3) pourraient etre une alternative pour evaluer la SV. Conclusion L’evaluation de la SV par l’ensemble des moyens cliniques ou paracliniques ne permet qu’une appreciation partielle de la SV. Une approche multidimensionnelle permettrait de mieux apprehender les troubles de la SV. more...

Vascular renal anomalies are frequent, multiple and well described and result from errors in vessel embryogenesis between the 6th and 10th week of gestation. Historically, variations are described in anatomic dissection and currently mostly in image interpretation. We report an anatomic variation concerning the right renal vein which, to our knowledge, has never been described in the literature either by dissection or by radiological examination. This variation was discovered during the routine dissection of an embalmed male body. It consists of a Y-shaped right renal vein and is associated with multiple retroperitoneal variations: a bilateral accessory renal artery, a trident ending of the right renal artery and a left testicular vein variation. Venous and arterial renal anatomy and its variations are fundamentally important in renal surgery, especially concerning living donor renal grafts. These variations may be diagnosed thanks to injected tomodensitometry which has a good sensitivity and specificity for anomalies. Preoperative diagnosis of an anatomic vascular renal variation may reduce morbidity during surgery, which is why precise examination of injected tomography should be mandatory. more...

Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Europeenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6 ± 23.7 to 52.6 ± 24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6 ± 24.2 to 48.7 ± 23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7 ± 23.7to 34.2 ± 20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted. more...

But L’electrostimulation est une option therapeutique reconnue des troubles vesicosphincteriens neurogenes. L’objectif de ce travail etait d’evaluer l’interet d’une technique non invasive de stimulation transcutanee du nerf tibial posterieur (STTP) sur les troubles mictionnels irritatifs (syndrome d’hyperactivite vesicale [HAV]) de patients porteurs de sclerose en plaques (SEP). more...

CT guided dual site infiltration in pudendal neuralgia Purpose. To assess the value of CT guided dual site infiltration in patients with pudendal neuralgia and determine prognostic factors of efficacy. Materials and methods. Retrospective review of 49 patients with suspected pudendal neuralgia who underwent one or multiple injections of local anesthetics and steroids. Patients were classified based on clinical and electrophysiological findings. Results. 70% of patients with typical symptoms of pudendal neuralgia responded favorably to the infiltrations compared to 27% of patients with atypical symptoms (p Conclusion. Infiltration is an effective treatment for patients with typical pudendal neuralgia, and should be included in the management of these patients. more...

Identifier les questionnaires de symptomes et de qualite de vie (QdV) specifiques des troubles urinaires ayant beneficie d’une validation psychometrique rigoureuse permettant leur utilisation pour mesurer l’efficacite d’un traitement. Une revue de la litterature a ete effectuee sur PubMed en utilisant les mots cles: urinary disorders, urinary incontinence, bladder, score, quality of life, questionnaire, psychometric validation. La selection des questionnaires a ete realisee selon les grades de recommandation de l’International Continence Society. Les articles concernant des essais therapeutiques ont ete exclus. Seuls les articles concernant la validation psychometrique des questionnaires ont ete retenus. Les questionnaires selectionnes mesuraient soit les symptomes urinaires et/ou la gene associee, soit la QdV specifique liee aux troubles urinaires. Ces questionnaires etaient pour la plupart specifiques des troubles urinaires de l’homme ou de la femme. Leurs qualites psychometriques n’etaient pas uniformes et, pour une majorite d’entre eux, la sensibilite aux changements n’avait pas ete analysee. Peu de questionnaires de QdV sont a un stade de validation permettant leur usage en pratique clinique. Une forme courte, sensible aux changements, est necessaire ainsi que l’extension de leur validite a d’autres populations pour les rendre plus faciles a utiliser en pratique clinique. more...

Resume Les troubles urinaires d’origine neurologique sont frequents. Ils sont la consequence de l’atteinte du systeme nerveux central et ou peripherique, somatique et ou vegetatif dont le role est d’assurer la regulation et le controle du fonctionnement du bas appareil urinaire. Du fait de la presence, au sein des structures du bas appareil urinaire, d’une double musculature, lisse et striee, les voies et les centres nerveux appartiennent a la fois au systeme nerveux somatique et vegetatif. more...

Une compression chronique du nerf pudendal dans un site d’etroitesse anatomique (syndrome canalaire) peut etre a l’origine de douleurs perineales invalidantes. Ce type d’atteinte doit etre diagnostique de facon specifique, car cela peut constituer une indication de neurolyse chirurgicale. Dans ce cadre, il est usuel de demander un examen electroneuromyographique (ENMG) du perinee, qui sera base sur l’etude de l’activite electromyographique de muscles perineaux, des reflexes sacres et des conductions motrices du nerf pudendal. Differentes considerations physiopathologiques et techniques expliquent certaines limites de l’ENMG qu’il faut connaitre. C’est ainsi que les methodes utilisees n’evaluent pas les anomalies fonctionnelles a l’origine des douleurs, mais plutot les alterations structurelles du nerf pudendal (demyelinisation ou perte axonale). De plus, seule l’innervation motrice directe ou reflexe est evaluee, alors que l’etude specifique des conductions sensitives serait sans doute plus sensible a objectiver une compression nerveuse. Enfin, il n’est pas possible de distinguer l’atteinte compressive des nombreuses autres causes de lesion nerveuse pudendale (chirurgicales, obstetricales, liees a une constipation chronique…). Ainsi, l’ENMG perineal a une sensibilite et une specificite limitees dans le diagnostic de syndrome canalaire pudendal et ne renseigne pas directement sur le phenomene douloureux. Le diagnostic de nevralgie pudendale repond en fait a des criteres cliniques precis et l’ENMG ne peut que donner des arguments supplementaires, mais non formels en faveur de ce diagnostic. L’ENMG perineal permet surtout de faire un « etat des lieux » de l’innervation perineale en prevision d’un geste chirurgical de decompression, et pourrait eventuellement fournir certains elements predictifs de l’interet de l’intervention. En revanche, l’ENMG ne permet generalement pas de localiser precisement le site de compression et n’a, dans tous les cas, aucune utilite dans la surveillance peroperatoire. more...

Qualiveen, questionnaire de qualite de vie (QdV), en langue francaise, specifique des troubles urinaires (TU) a beneficie d’une procedure rigoureuse de traduction en langue anglaise. Cependant cette premiere etape d’une adaptation culturelle d’un questionnaire ne garantit pas sa pertinence interculturelle. S’assurer de l’equivalence du concept mesure par le questionnaire entre les cultures concernees est un prerequis necessaire. Une adaptation culturelle est ainsi achevee quand les proprietes de mesures du questionnaire traduit ont ete demontrees. Prouver l’equivalence conceptuelle de la version anglaise de Qualiveen avec la version originale francaise, en analysant ses proprietes demesures (validite de construction, fiabilite et sensibilite aux changements). Etude longitudinale chez 55 patients canadiens anglophones, atteints de SEP qui ont rempli a deux reprises Qualiveen en anglais, le Multiple Sclerosis Quality Of Life-54 et une auto-evaluation des TU. A l’inclusion, chaque patient a ete inclus soit dans le groupe «stable par anticipation» (si les troubles urinaires etaient peu genants, traites ou non), soit dans le groupe «ameliore par anticipation» (si un traitement etait instaure et que nous presumions fortement que ce traitement les ameliorerait). La validite de construction longitudinale de Qualiveen repose sur la confirmation de predictions faites a priori (Kappa = 0,71) avec des changements observes dans les scores de Qualiveen correles aux changements des autres questionnaires. Sa fiabilite est elevee (coefficient de correlation intraclasse = 0,94). Tous les domaines de Qualiveen sont capables de detecter des changements chez les patients «ameliores par anticipation» (p < 0,0001) et de differencier ces patients de ceux restes «stables» (p < 0,0001). Les proprietes de mesures de Qualiveen en anglais sont similaires a celles de la version originale. Cette validation psychometrique permet l’utilisation d’un questionnaire de QdV equivalent dans l’evaluation des TU chez des patients atteints de SEP, de cultures differentes, au cours d’etudes internationales. more...

Objectives To identify all available symptom and quality of life questionnaires for men and women with urinary disorders and assess their psychometric properties. Methods We systematically reviewed the literature in Medline using the key words urinary disorders, urinary incontinence, bladder, score, quality of life, questionnaire, and psychometric validation. Results The first search using the terms urinary incontinence and quality of life resulted in 1018 Abstracts. Articles mentioning but not measuring quality of life were not investigated. Questionnaires were selected because their psychometric properties were tested and they assessed how much a person was bothered by urinary symptoms or quality of life specific to urinary disorders. The questionnaires were usually gender specific. Their psychometric value was far from uniform, and, for most, responsiveness was not reported. Conclusion Few quality of life questionnaires are at an advanced stage of validation to be applied in clinical practice. They need to be shorter, responsive and validated in different populations to permit their easy use. more...

Resume INTRODUCTION : Chez le blesse medullaire, la percussion sus-pubienne est un puissant stimulus capable de declencher une contraction vesicale. Elle sˈaccompagne en regle dˈun renforcement de lˈactivite striee perineale. Si cette reponse des muscles perineaux a la stimulation sus-pubienne a ete mentionnee chez lˈanimal, elle nˈa jamais ete specifiquement etudiee chez lˈhomme tant spinal quˈindemne de lesion neurologique. OBJECTIFS : Decrire lˈexistence dˈun reflexe pubo-caverneux et analyser ses caracteristiques electrophysiologiques. MATERIEL ET METHODE : Vingt et un patients neurologiquement sains, consultants pour des troubles mictionnels ont ete examines. Il sˈagissait de 14 femmes et de sept hommes, dˈâge moyen 51 ans (ecart type = 14,2). Les symptomes etaient pour les femmes une incontinence urinaire a lˈeffort pure dans dix cas et une incontinence par imperiosite dans quatre cas ; tous les hommes (7/7) souffraient de signes irritatifs (pollakiurie, imperiosite) dont trois secondaires a une hypertrophie benigne de la prostate. Chaque patient a eu une etude du reflexe pubo-caverneux avec analyse des reponses electromyographiques du muscle bulbo-caverneux par electrode aiguille apres stimulation mecanique supra pubienne a lˈaide dˈun marteau electronique. RESULTATS : La reponse electromyographique verifiee par deux fois est stable et reproductible (analyse de variance avec p DISCUSSION : Cette etude demontre lˈexistence chez lˈhomme normal dˈun reflexe pubocaverneux. Les reponses obtenues ont les caracteristiques dˈun reflexe polysynaptique (latence courte le differentiant dˈune contraction volontaire, jitter, habituation, caractere polyphasique, latence proche de la reponse R2 polysynaptique du reflexe bulbo-caverneux electrique). Lˈintegration de ce reflexe est vraisemblablement sacree, lˈeffecteur etant le nerf pudendal et lˈafferent possiblement le nerf pelvien. Les recepteurs stimules sont probablement les tenso-recepteurs detrusoriens. CONCLUSION : Chez lˈhomme spinal, ce reflexe entre tres certainement en competition avec le reflexe proprioceptif cutaneo- ou vesico-detrusorien (declenchement de la contraction vesicale par percussion sus-pubienne) et represente probablement ainsi dans certains cas un obstacle a une vidange complete de la vessie. Chez le sujet normal, il sˈagit dˈun reflexe de continence, permettant une contraction perineale reflexe a un stimulus susceptible dˈengendrer une hyperpression abdominale. more...

Summary Background Provoked vestibulodynia is difficult to treat. The beneficial effects of botulinum toxin A are being considered because of the muscular anomalies observed in this pathology. Objective To evaluate the efficacy of botulinum toxin A in the treatment of provoked vestibulodynia. Methods Patients aged between 18 and 60 years presenting with provoked vestibulodynia (according to the 2003 International Society for the Study of Vulvar Disease classification) received 50 U of botulinum toxin A bilaterally in the bulbospongiosus muscle under electromyographic monitoring. Pain was evaluated by a visual analogue scale (VAS), quality of life was evaluated by the Dermatology Life Quality Index and sexual function by the Female Sexual Function Index. Results Twenty patients received the injections. Sixteen patients presented with a muscular hyperactivity on electromyography. After 3 months, 80% of the patients improved in terms of pain. Mean ± SD VAS values significantly decreased from 8·37 ± 1·22 (range 4·5–10) to 2·57 ± 2·67 (0–9; P more...

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.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.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 (p0.0001) and significant improvement in maximum cystometric capacity (p0.0001). The test was considered positive in 22 of the 44 patients.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. more...