Biomedical subjects
Publications and source records attributed to A J Pavlakis.
Three cases of vesicouterine fistuli secondary to cesarean section are reported. The first 2 cases presented as vaginal urinary incontinence and cyclic hematuria, whereas the last case presented as bloody urinary loss from the vagina in the immediate postoperative period. The treatment was surgical in the former 2 cases and conservative in the latter case. The literature is briefly reviewed, and the treatment options are discussed.
The endogenous production of prostaglandins and thromboxane A2 by the rabbit urinary bladder was assessed by radioimmunoassay in a relatively intact system and in the absence of substrate. PGE2 and PGI2 (prostacyclin) were the main prostaglandins released whereas PGF2 alpha ratio of 5:1 and a PGI2 to PGF2 alpha ratio of 3:1 were observed. This qualitative pattern was independent of bladder area. In addition, prostaglandin release by the bladder body was significantly greater than by the bladder base at all incubation times. The physiological implications of these experimental observations are discussed.
Fifty-seven patients with documented conus medullaris and cauda equina injury underwent neurourologic evaluation consisting of cystometrography (CMG), perineal floor electromyography (EMG), and bethanechol chloride supersensitivity testing (BST). The bulbocavernosus reflex was normal in only 16% of the patients, and perineal sensation and muscle stretch reflexes were absent or significantly diminished in 77%. The predominant CMG finding was detrusor areflexia (93%). Neuropathic EMG changes were noted in 67% and a positive BST response in 95% of the cases. Statistical analysis showed significant correlations between (1) a compromised bulbocavernosus reflex and perineal floor neuropathy (.01 less than P less than .05) and (2) sex of the patient and incidence of urinary incontinence among subjects with perineal floor neuropathy (P less than .01). The major neurourologic features in these patients (1) An absent or substantially diminished bulbocavernosus reflex, (2) detrusor areflexia on CMG, (3) neuropathic perineal EMG changes, and (4) a positive BST response.
The changing clinical course of multiple sclerosis is a hallmark of the disease. The neurourologic findings in this disorder have been well documented in the literature but the occurrence of urodynamic changes with time has been mentioned only briefly. Ten men and 8 women had 2 or more urodynamic evaluations, consisting of cystometrography and perineal floor needle electromyography during 2 months to 6 years (mean 25 months). The initial urodynamic patterns included a normal study in 1 patient, detrusor areflexia in 7 and detrusor hyperreflexia in 10 (5 with vesicosphincter dyssynergia). Re-examinations were done for persistent or new symptoms. The urodynamic pattern changed in 10 patients (55 per cent), including cystometrographic changes in 7, newly developed neuropathic changes on electromyography in 5 and changes in detrusor-sphincter interaction in 9 (with 5 new cases of vesicosphincter dyssynergia). Of the 8 patients who did not demonstrate a urodynamic change 5 had vesicosphincter dyssynergia that persisted on followup. Vesicosphincter dyssynergia was the predominant pattern noted on re-evaluation, acting as a urodynamic indicator of progressive multiple sclerosis. Careful neurourologic assessment should be performed routinely in the followup of multiple sclerosis patients who are unresponsive to treatment or who manifest new symptoms.
A total of 30 patients with an established diagnosis of Parkinson's disease and symptomatic voiding dysfunction underwent neurourologic evaluation. Detrusor hyperreflexia associated with appropriate sphincter relaxation was found to be the most common urodynamic pattern, occurring in 75 per cent of the cases. Two types of increased electromyogram activity at the time of detrusor contraction were identified: 1) pseudo-dyssynergia (7 per cent)--a voluntary contraction of the perineal floor in an attempt to prevent leakage and 2) sphincter bradykinesia (11 per cent)--a manifestation of skeletal muscle hypertonicity characteristic of parkinsonism. On the basis of these observations it is assumed that the effect of the basal ganglia on micturition is inhibitory in nature. The diagnostic and therapeutic approach to the parkinsonian patient with voiding dysfunction is discussed.
A total of 26 patients with symptomatic voiding dysfunction underwent cystometrography concomitant with simultaneous perineal floor and rectus abdominis electromyography. Of the patients 20 had well defined neurological pathological conditions. Cystometrography/perineal electromyography revealed detrusor hyperreflexia with appropriate sphincter relaxation in 8 patients, with vesicosphincter dyssynergia in 10 and with pseudo-dyssynergia in 2. Rectus electromyography in these patients did not reveal electromyographic activity during the filling and expulsion phases of the cystometrogram. However, the 6 neurologically normal patients were noted to have detrusor areflexia with nonrelaxation of the sphincter on urodynamic examination. These patients characteristically attempted to void by abdominal straining, resulting in a concomitant increase in rectus and perineal electromyography activity. We conclude that the addition of rectus electromyography to the standard urodynamic methodology can improve significantly the recognition of intravesical pressure elevation owing to voluntary contraction of the abdominal musculature.
We investigated 63 patients with detrusor areflexia by cystometrography, perineal floor electromyography and bethanechol chloride supersensitivity testing. Of the patients 48 had unequivocal evidence of neuropathy, while 15 were neurologically normal and served as controls. The bethanechol chloride supersensitivity test was positive in 98 per cent of the patients and none of the controls, whereas neuropathic changes by electromyography were found in 67 per cent of the patients and 7 per cent of the controls. These findings suggest that the bethanechol chloride supersensitivity test is more sensitive and more specific than perineal floor electromyography in corroborating bladder neuropathy.