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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.

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.

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.

Introduction La vestibulodynie provoquee (VP) est une douleur vulvaire chronique de type allodynie, localisee, provoquee par le contact et l’activite sexuelle, sans cause claire identifiable. L’un des mecanismes suspectes est une sensibilisation accrue vulvaire provoquee par une augmentation des nocicepteurs vanilloides. La capsaicine agit sur ceux-ci engendrant une antalgie. Materiel et methodes Cet essai therapeutique etudiait les effets antalgiques de la capsaicine en patch a haute concentration (8 %), pour le traitement des VP, chez dix femmes, chacune suivie pendant 12 semaines au CHRU de Besancon. L’objectif principal etait d’etudier l’efficacite de ce traitement sur la reduction de la douleur a l’aide d’une echelle visuelle analogique (EVA). Les objectifs secondaires etaient d’etudier la qualite de vie (DLQI), la fonction sexuelle (FSFI) et la tolerance du traitement durant la periode de suivi. Resultats L’EVA moyenne a diminue, non significativement, de 22,5 %, apres la mise en place du traitement (4,9 a S0 et 3,87 a S12). Le DLQI moyen s’est ameliore significativement de 28 % pendant les deux premieres semaines (p = 0,027). Le FSFI moyen s’est degrade, non significativement, pendant le suivi. La tolerance etait bonne et aucun effet secondaire systemique n’etait note. Discussion L’absence de mise en evidence d’efficacite du patch de capsaicine peut s’expliquer par les facteurs physiopathologiques multiples impliques dans la VP, notamment l’hyperactivite musculaire sur laquelle la capsaicine en topique n’a aucun effet, l’absence d’autres therapeutiques associees et le faible effectif de notre population. Conclusion Pour confirmer ou infirmer l’efficacite de la capsaicine en patch a haute concentration, un essai therapeutique controle, comprenant un plus grand effectif et associant d’autres therapeutiques a la capsaicine, est necessaire.

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.

Few data exist on the feasibility and reliability of measuring muscular atrophy in 2 dimensions (2D) by ultrasonography (US) and elasticity with shear wave elastography (SWE) in spastic muscles.Fourteen patients with chronic stroke took part in 2 intersession reliability experiments performed with 1-week intervals between sessions. Pennation angle (PA), muscle thickness (MT), and shear elastic modulus (µ) were measured in spastic gastrocnemius medialis (GM) muscles at rest and at maximal passive stretching in paretic and nonparetic legs.On the paretic side, the coefficient of variation (CV) in GM was 6.30% for MT and 6.40% for PA at rest and was 7.53% and 8.26% for MT and PA, respectively, at maximal passive stretching. The reliability of the µ measurement was good only for GM at rest on the paretic side (CV = 9.86%).2D US associated with SWE shows promise for assessing structural changes in muscles. With some methodological adaptations, this approach could help guide spasticity treatment. Muscle Nerve 57: 222-228, 2018.

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).

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.

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.

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.

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.

Resume Introduction. – 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 garantie 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. Objectif. – Prouver l'equivalence conceptuelle de la version anglaise de Qualiveen avec la version originale francaise en analysant ses proprietes de mesures discriminatives (fiabilite et validite de construction). Methodes. – Cinquante-cinq patients canadiens anglophones presentant une sclerose en plaques (SEP) ont complete a deux reprises Qualiveen en anglais, le multiple sclerosis quality of life-54, une evaluation des TU et ont beneficie d'une mesure de leur EDSS (expanded disability status scale). Resultats. – La version anglaise de Qualiveen a une fiabilite elevee (coefficient de correlation intraclasse egal a 0,94). Sa validite de construction repose sur la confirmation de predictions faites a priori (kappa = 0,65) avec des correlations fortes entre Qualiveen et le degre d'incontinence (0,63), moderees avec les symptomes urinaires (0,49), faibles avec le mode mictionnel (0,28) et faibles ou absentes avec les domaines de MSQOL-54 et l'EDSS. Conclusion. – 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.

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.

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.

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.

The aim of this work was to carry out a review of the literature on the clinical and paraclinical evaluation of bladder sensory (BS) to better understand BS disorders in nonneurological patients.Thirty-three articles were selected from the Medline(®) Database between 1992 and 2012 using the following key words: "sensory/sensitivity bladder evaluation", "sensory/sensitivity bladder scale", "sensory/sensitivity bladder questionnaire", "urodynamic bladder sensory", "urgency questionnaire" and "Overactive Bladder (OAB) questionnaire".Evaluation of BS by asking questions during cystometry is validated (LE 2). The sensation of the desire to void progresses linearly with bladder filling (LE 2). Many symptoms and quality of life questionnaires related to BS anomalies have been proposed. Bladder diaries, frequency/volume curves (LE 2) and clinical algorithms (LE 3) could be an alternative to evaluate BS.Current evaluation only provides a partial view of BS. A multidimensional approach should lead to better understanding of BS disorders.

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

Le diaphragme urogenital n’est pas retrouve en radio-anatomie. La region perineale profonde est en continuite avec la cavite pelvienne par l’intermediaire du hiatus urogenital delimite par les bords internes des muscles elevateurs de l’anus droit et gauche. Le sphincter strie uretral encercle plus ou moins completement l’uretre membraneux qui peut etre ainsi appele « uretre sphincterien ». Il est plus facilement observe en IRM sur des coupes frontales effectuees avec une antenne endorectale. Son developpement est variable et il peut posseder une portion « intraprostatique ».

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.70% of patients with typical symptoms of pudendal neuralgia responded favorably to the infiltrations compared to 27% of patients with atypical symptoms (p0.05). The mean number of infiltrations was 2.2. 84% of responding patients experienced symptomatic relief after the first infiltration. The mean duration of symptomatic relief was 3 months.Infiltration is an effective treatment for patients with typical pudendal neuralgia, and should be included in the management of these patients.

International audience; OBJECTIVE: To define the vascular and nervous relationships of the uterosacral ligament and to analyze histologically its content for a better description of this structure. MATERIALS AND METHODS: Three fresh fetal cadavers, three embalmed and one fresh adult cadavers were used. The anatomical relationships of the uterosacral ligament were studied by dissecting one fresh fetal pelvis and two embalmed adult pelves. By histological and immunohistological examinations, eight biopsies of the cervical origin of the complexe ligamentaire utérosacral (USLC) were analyzed: four from fresh fetuses, two from a fresh adult cadaver and two from an embalmed adult cadaver. The specimens were stained with haematoxylin eosin safran (HES) coloration, with antinervous cell specific antibodies (PS100) and with antismooth muscle actine antibodies (to visualize vessel walls) before examination under optical microscope. RESULTS: On anatomic examination, the uterosacral ligament was covered by the visceral pelvic fascia. By removing this fascia, the uterosacral ligament appeared to be a condensation of nervous fibers made up of hypogastric and pelvic nerves forming the hypogastric plexus. Histologically, the uterosacral ligament contained connective tissue, nervous fibers, sympathetic nodes, vessels and fatty tissue. No structured ligamentous organization was identified. CONCLUSION: The uterosacral "ligament" is in fact a "ligament complex" integrating connective tissue as well as nervous and vascular elements. Radical wide excisions of the USLC during cancer or endometriosis surgery and uterosacral suspension during pelvic floor reconstructive surgery should be performed with caution in order to preserve pelvic innervation.

Les troubles urinaires et anorectaux sont reconnus pour alterer la vie quotidienne des patients. Ils sont responsables de troubles du sommeil, de depression, ďanxiete de mauvaise estime de soi et ďisolement social (1, 2, 3). Ils sont explores au cours ďun bilan clinique et paraclinique relativement standardise: interrogatoire, calendriers mictionnel ou fecal, examen clinique neuroperineal et urogenital, explorations urodynamiques, ou manometriques, et electrophysiologiques.

Clean intermittent self-catheterization is the recommended mode of bladder voiding in patients with urinary retention. Hence, this procedure should be well known and understood by the general practitioners (GP) who are responsible for monitoring such patients.To assess GP' state of knowledge regarding clean intermittent self-catheterization and to make recommendations for dealing with problems that occur during patient follow-up.A questionnaire focusing on the practice of clean intermittent catheterization was sent to 910 family GP in the Franche-Comté region of eastern France.Two hundred and fourty-six replies were analyzed. Sixty-four percent of GP believed that the appropriate number of bladder catheterizations per day was between two and four. Ninety percent of the GP prescribed perineal cleaning before catheterization and 29% prescribed the use of sterile gloves. Eighty-seven percent of general practitioners considered urinary tract infection to be the main complication of intermittent catheterization. Thirty percent always requested a urine culture in patients performing self-catheterization and 29% prescribed antibiotic therapy in cases of bladder colonization.General practitioners need to receive additional information on the role of clean intermittent catheterization in the prevention of urinary tract infection. In accordance with the French Urology Association guidelines, we produced a practical summary guide on preventing asymptomatic bacteriuria and urinary tract infections and/or preparing for urological investigations.

Neurogenic lower urinary tract dysfunction is frequent, due to lesions of the central and/or peripheral somatic and/or autonomic nervous system whose role is to ensure the regulation and control of lower urinary tract function. Due to the presence of both smooth and striated muscle cells in structures of the lower urinary tract, nerve pathways and nerve centres belong to both the somatic and autonomic nervous systems.

The Qualiveen questionnaire is a urinary disorder-specific health-related quality of life (HRQL) instrument. Developed in French, the instrument's translation into English was the first step of a process leading to an HRQL questionnaire that can be used in a different culture. However, the cultural adaptation of an HRQL questionnaire is achieved only when the psychometric properties of the translated questionnaire are documented.To develop an equivalent English version of the Qualiveen questionnaire and to assess its discriminative measurement properties.Fifty-five Canadian out-patients with multiple sclerosis (MS) completed a set of questionnaires, including the Qualiveen; the MS Quality Of Life-54 (MSQOL-54), an MS-specific HRQL questionnaire; urinary function assessment; and the expanded disability status scale (EDSS) twice at an interval of 2 to 4 weeks.The English Qualiveen proved to be test-retest reliable (intraclass correlation coefficient=0.94). Consistent with a priori predictions, we found a strong association between overall Qualiveen score and degree of incontinence (0.63), a moderate association with type of urinary symptoms (0.49), a weak association with manner of voiding (0.28) and weak or absent associations with MSQOL-54, EDSS bladder/bowel and global EDSS domains. Predictions proved to be generally accurate (weighted kappa=0.65).The test-retest reliability and cross-sectional construct validity of the English version of Qualiveen are excellent and similar to the original French version. Further studies should explore Qualiveen's longitudinal validity and responsiveness.

The rules of gymnastics impose an element of static strength such as an iron cross (IC) on the rings. For IC training, coaches use a custom made device -- the herdos -- to simulate the conditions of competition. The purpose was to compare muscle activity and coordination during IC performed both on the rings and using herdos. Secondly, we tried to determine whether herdos usage induced functional adaptations of the shoulder muscles.Six male gymnasts performed 10 IC in each condition. Surface electromyogram of muscles pectoralis major, latissimus dorsi, teres major, infraspinatus, rhomboideus, trapezius, serratus anterior, biceps brachii, and triceps brachii in the right shoulder were analysed using root-mean-square (RMS), and muscle part's in each condition. Muscle part represents the contribution of each of the 9 shoulder muscles studied in each condition. Total muscle activity (SUM) was also used to compare the 2 conditions.Except for the muscle teres major, the RMS decreases (p0.05) when using the herdos. The SUM also decreases (p0.05) when using this device. The muscle parts indicate that the contribution of the muscle latissimus dorsi decreases (p0.05) when using the herdos. These results suggest that the herdos modified shoulder coordination. But their usage does not seem to induce any functional adaptations of these muscles.The herdos do not seem to provide a valid method to reproduce the same shoulder coordination as on the rings. Therefore IC training with this special device could be called in question.

To identify all available symptom and quality of life questionnaires for men and women with urinary disorders and assess their psychometric properties.We systematically reviewed the literature in Medline using the key words urinary disorders, urinary incontinence, bladder, score, quality of life, questionnaire, and psychometric validation.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.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.

The aim of this work is to sum up how the use of EMG improves BT therapy.A systematic review of the literature in the Pub Med computer database, along with a manual biography, allowed us to choose the most synthetic and the most pertinent publications according to our own practical experience.There is no consensus of opinion, but the great majority of authors emphasize the importance of EMG in the different stages of botulinum toxin treatment: before injections, at the time of the injection, and finally during the follow-up after the first injection or after the repeated injections that transient efficiency make necessary.A symptomatic therapeutic means recently recognized in focal dystonias and spasticity, BT is injected locally into the muscles to be treated. EMG can be used: at pre-injection for physiopathological evaluation but above all to establish a diagnosis and precise pre-intervention evaluation; at the moment of injection to provide guidance in precise muscle selection and for maximum efficiency with reduced, therefore less costly, doses. It also limits the risk of product diffusion susceptible of causing iatrogenic side effects and/or auto-immunisation resulting in resistance to the toxin; during follow-up, to understand why treatment failed and to look for changes in the dystonia pattern leading to objective re-evaluations and adapted reinjections. Although neglected by some, electrological logistics seem to us, as to many other practitioners who inject, to be a considerably helpful aid, particularly at the moment of injection when targeting the muscle to be treated.

The first clinical studies indicate that Botox provides effective treatment for hyperhidrosis and sialorrhea. The aim of this work is to sum up current evaluation of this use.A systematic literature search was conducted on the Pub Med database, along with on chapters in other publications. The most interesting articles in relation to our own personal experience were chosen.Despite recent use of BT to treat focal hyperhidrosis, there have been numerous publications since 1997. However, the injected areas have not been listed so frequently. Axillary hyperhidrosis has been studied most; it is also in this case and in the case of gustatory sweating that the best results have been obtained. Publications about palmar and especially plantar hyperhidrosis are much rarer, almost anecdotic. It has been demonstrated to a lesser extent that BT injections are effective in these cases. Literature about sialorrhea is just beginning. However, the reduction of the production of saliva following intra parenchymatic injection of toxin into the parotid and submandibular glands, thus rarifying drooling, has been demonstrated. For each of the pathological indications, both the injection techniques and the optimal doses remain to be determined.Because BT blocks all cholinergic transmission, including the autonomous nervous system, it was plausible to expect a reduction in sweating and salivation on local injection of the product. In fact, the first publications indicated such efficiency without serious side effects. For hyperhidrosis, there has developed a consensus for making intracutaneous injections only. Of the injections in axillary areas, the palms of the hands, the plantar regions, the face or other cutaneous areas, palmoplantar hyperhidrosis is the least accessible, in any case causes the most technical problems, because of difficulty in pain management. For sialorrhea and the drooling that accompanies certain chronical neurological diseases, BT seems to have very promising effects. However, it has not been precisely determined whether to inject the parotid gland, the submandibular gland, or both. Necessary and sufficient means of targeting are still imprecise. It also remains to be determined the number of sites per gland and the doses to be injected.

Botulinum toxin (BT) injection into the external urethral sphincter is a promising therapy for neurogenic voiding disorders due to detrusor-sphincter dyssynergia (DSD). However the optimal treatment protocol remains unclear.A PubMed reference search and manual bibliography review were performed, along with a search in the Annales de réadaptation et de médecine physique and in the reports of the International French-language Society of Urodynamics and the International Continence Society, which allowed us to select twelve pertinent articles with PubMed, two articles from the Annales and two conference reports. Our analysis gave special emphasis to assessment criteria, application, dosage and BT injection technique.Used for the first time in 1988 in spinal cord injury patients to reduce outflow obstruction due to DSD, BT injections have been shown to be a valuable alternative management of bladder dysfunction with DSD. They have been proposed in neurological patients unable to perform self-catheterisation, after drug failure and before surgery. Parameters for results assessment are mostly clinical (increased free interval between voiding, decreased post-void residual urine volumes), urodynamic (improvement in bladder emptying, increase in functional bladder capacity and decrease in urethral pressure) and electromyographic (denervation of striated urethral sphincter). The literature data regarding type of BT, dosage and protocol vary widely. Duration of action is from 2 to 12 months. Both transurethral and transperineal injections monitored by EMG are equally effective in improving detrusor-sphincter dyssynergia.With few side effects and satisfactory medium-term results, BT should be recommended as a component of DSD therapies. We propose a practical method for BT use.

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.

In spinal cord injuries patients, tapping the suprapubic aera is a strong stimulus to ellicit detrusor contraction and can be used in the management of neurogenic bladder. This stimulation also determines a perineal muscles contraction. This striated response was mentionned in animal studies but never specifically analysed in men especially in normal subjects.Our objective was to describe pelvic floor responses with measurement of reflex latency following suprapubic mechanical stimulation.21 patients without neurological disease were studied. They were 14 women and 7 men. Mean age was 51 (SD=14,2). Motor responses were recorded with a needle electrode inserted in the left bulbocavernosus muscle. Stimulation was delivered with an electromechanical hammer, tapping directly on the suprapubic aera.A polyphasic muscular response was always and easily elicited in all patients. Mean latency was 67,5 ms. (SD = 14,7). The reproducibility between the first and second mechanical responses was good with no statistical difference (r=0,966; p=0,0001).Our study clearly demonstrates a suprapubic bulbocavernosus reflex (SBR). Many arguments can be retained for a polysynaptic reflex (polyphasic response, habituation and short latency of the reflex, mean latency in the habitual values of R2 responses following electrical stimulation of the dorsal nerve of the penis). We hypothetize that: the true stimulus is the stimulation of the bladder wall tenso-receptors; integration level of the SBR is the sacral segments and the efferent limb the pudendal nerve; afferent pathways could be vehicled by pelvic nerve fibers.Competition between a preponderant (or exaggerated) SBR and a bladder contraction following suprapubic tapping, may constitute a real functional outlet obstruction giving incomplete or complete retention in some suprasacral bladders. In normal subjects, SBR can be considered as a continence reflex with increase of perineal tone following the stimulation of the bladder wall tenso-receptors during stress.

Introduction Les vestibulodynies provoquees representent la forme clinique la plus frequente des vulvodynies. Il s’agit d’une allodynie du vestibule vulvaire responsable d’une dyspareunie d’intromission et d’inconfort au moindre contact. Une augmentation de l’innervation intra-epitheliale du vestibule (recepteurs membranaires vanilloides sous type 1) a ete mise en evidence chez les patientes atteintes de vestibulodynies provoquees (VP). La capsaicine agit specifiquement sur ces recepteurs et pourrait avoir un role antalgique sur ces douleurs. Observations Cinq patientes presentant une VP ont ete traitees par preparation magistrale (PMR) a 0,025 % de capsaicine, une fois par jour sur le vestibule vulvaire, pendant 3 mois. L’evaluation de la douleur provoquee (echelle visuelle analogique : EVA) a ete effectuee avant et apres traitement. Resultats La moyenne d’âge au moment du diagnostic etait de 22 ans. Les 5 patientes avaient des antecedents de candidoses vulvo-vaginales. Quatre sur 5 avaient des cystalgies a urines claires et 2 une colopathie fonctionnelle. Toutes les patientes avaient ete traitees par antalgiques (antidepresseurs, anti-epileptiques) et kinesitherapie perineale. Trois patientes avaient recu des injections de toxine botulinique A dans les muscles vaginaux. La moyenne des EVA provoquees, avant traitement par capsaicine, etait de 4,6 (3 a 8) avec un score DLQI moyen de 7,4. Apres traitement, l’EVA moyenne etait de 1,2 (0 a 3) avec un DLQI moyen a 2,5. Une patiente a arrete le traitement des la premiere application, en raison de brulures. Pour les 4 autres, le seul effet secondaire etait une sensation de brulure sans erytheme vulvaire, durant environ 20 minutes et s’attenuant en quelques jours. Pour 2 patientes, l’application de la PMR avait permis la diminution du traitement medicamenteux. Discussion Nous confirmons que les VP touchent les femmes jeunes. Le role d’une infection vulvaire precedent la vulvodynie a ete rapporte et se confirme dans notre serie. La physiopathologie impliquerait une part neurologique mixte : douleur neuropathique et dysfonctionnelle avec sensibilisation centrale. Ceci expliquerait l’association a des cystalgies et a un syndrome du colon irritable. Aucun traitement de reference efficace n’existe. Apres plusieurs traitements, toutes nos patientes avaient une EVA superieure ou egale a 3, avec retentissement sur la qualite de vie. La capsaicine est une neurotoxine qui se lie aux recepteurs membranaires vanilloides de type 1 des fibres C. Lors d’applications repetees, elle induit un blocage durable de la conduction nerveuse. Nos resultats sont encourageants. Le facteur limitant est la tolerance. Quatre series ont etudie la capsaicine topique dans le traitement des VP, aucun effet secondaire grave n’a ete rapporte a ce jour. Conclusion La capsaicine topique pourrait constituer une nouvelle option therapeutique dans la prise en charge des VP.

Introduction La prise en charge de la pathologie neurovasculaire evolue depuis plusieurs annees modifiant le statut vital et fonctionnel des patients. Objectifs Nous realisons une analyse epidemiologique du devenir des patients avec un premier accident vasculaire cerebral (AVC) sur une longue periode et sur une population non selectionnee. Methodes Nous avons etudie l’evolution du nombre de deces sur 20 ans, et du handicap par l’indice de Rankin, ainsi que l’etat clinique a l’entree dans le service de neurologie chez les patients ayant presente un premier AVC identifie dans un registre continu de population sur la periode 1985-2004. Resultats La repartition du type d’AVC etait la suivante : 3 142 infarctus, 341 hematomes et 74 hemorragies meningees. Sur 20 ans, la mortalite a baisse de 0,94 p. 100 par an (p Discussion La baisse de la mortalite observee a Dijon confirme la tendance observee dans la plupart des autres registres. Le registre de Dijon est cependant le seul a etre continu. L’amelioration de l’evolution des patients avec un AVC est notable malgre l’augmentation de l’âge de survenue du premier evenement. Conclusion Sur une periode de 20 ans, il a ete observe a Dijon, une diminution de 50 p. 100 de la mortalite des patients avec un AVC sans majoration du handicap lourd.

Objectifs Evaluer l’efficacite de l’infiltration scano-guidee sur les deux sites de conflit du nerf pudendal chez des patients suspects de nevralgie pudendale, et determiner des facteurs pronostiques. Materiels et methodes Etude retrospective de 107 infiltrations realisees chez 49 patients suspects de nevralgie pudendale dans le service de radiologie A et C du CHU de Besancon. Les patients ont ete classes selon differents groupes suivant des criteres cliniques et electrophysiologiques. Resultats Les patients qui presentaient une symptomatologie typique de nevralgie pudendale ont repondu dans 70 % des cas aux infiltrations et ceux ayant une symptomatologie atypique dans 27 % des cas : il existait une difference statistiquement significative (p Conclusion L’infiltration scano-guidee est un moyen efficace de traiter les patients ayant une nevralgie pudendale s’ils ont une symptomatologie typique, et se positionne comme une piece maitresse dans la prise en charge de ces patients.