No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Is There an Association Between Female Urinary Incontinence and Decreased Genital Sensation?
Abstract
To explore the relationship between urinary incontinence and genital sensory functioning in females with sexual dysfunction disorders.
A retrospective consecutive chart review was conducted for all women who were referred to our tertiary female urology clinic with a primary complaint of sexual dysfunction between October 1999 and January 2009. Our study sample included 177 women, all of whom underwent a thorough clinical evaluation. Urinary incontinence was diagnosed based on clinical history and physical examination by a urogynecologist. The Genital Thermal and Vibratory Sensory Analyzer (GSA) was used for sensory testing in the genital area. Independent t-test and multivariate linear regression were used for statistical analysis.
Of the 177 study patients (median age 34, range 18-68), 63 (36%) had urinary incontinence. Women with urinary incontinence were found to be less sensitive to warm, cold, and vibratory thresholds at both the anterior and the posterior vaginal wall and the clitoral area (P < 0.05).
Women with urinary incontinence and sexual dysfunction are less sensitive to all sensory testing in the genital region than women with sexual dysfunction alone. This relationship may be attributable to afferent nerve damage and the critical role it may play in the etiology of urinary incontinence.
... Intensity can be an important parameter to consider among aging women and women with urinary incontinence, multiple sclerosis, and/or sexual dysfunction. 10,11 These groups of women might require higherintensity vibration to achieve arousal and orgasm. [12][13][14][15][16] Vibration and vasodilation Vibration facilitates vasodilation and blood flow in the pelvic floor muscles 10 and was found to promote muscle group stretching and shortening and increase metabolic rate in skeletal muscles. ...
Introduction
Vibrators and similar devices are an underutilized treatment modality in pelvic and sexual medicine, likely because of the limited knowledge on the health benefits of their use.
Objectives
The aim of this study was to review available data regarding the effect of vibrator use on sexual function, pelvic floor function, and chronic unexplained vulvar pain.
Methods
We performed a systematic literature review of PubMed, Embase, and MEDLINE from inception to March 2021 per the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). The search was based on the following keywords: sex toy woman, pelvic vibrator, sexual stimulation vibrator, vaginal vibrator, vibrator pelvic floor, vibrator incontinence, and vulvar pain vibrator. An overall 586 articles were identified. Studies that met inclusion criteria were reviewed: original research, sample of women, vibrator use, and application to the pelvic/genital area. Exclusion criteria included case reports, unrelated content, vibrator not applied to the pelvic/genital area, male participants, or conditions of interest not addressed. A total of 17 original studies met the criteria and were reviewed in depth.
Results
After review of the literature and identification of articles appropriate for the study, there were 8 studies surrounding sexual function, 8 on pelvic floor function (muscle strength/urinary incontinence), and 1 on vulvar pain. Among the identified studies, vibrators were considered an accepted modality to enhance a woman’s sexual experience, improve pelvic floor muscle function, and facilitate treatment of vulvar pain.
Conclusions
Vibrators are not well studied, and given the promising benefits demonstrated in the articles identified, future research efforts should be directed toward investigating their utility. Considering the potential pelvic health benefits of vibrators, their recommendation to women could be included in our pelvic floor disorder treatment armamentarium.
... (1,2) Women with pelvic oor dysfunction have evidence of pudendal sensory and motor nerve impairment. (3)(4)(5)(6)(7) One major factor in the development of pudendal motor nerve injury is childbirth. Research to date has described injury to pudendal motor nerves following vaginal birth whilst pregnancy itself had no effect. ...
Pelvic organ prolapse, urinary, bowel and sexual dysfunction, collectively called pelvic floor dysfunction (PFD) affects 1 in 3 women and has a significant public health impact. The causes of PFD are not fully understood but involve injury to connective tissue and motor nerve during childbirth. Women with PFD also have sensory nerve impairment, and it is likely this occurs during childbirth, but this has never been investigated.
In the current study 150 women underwent quantitative sensory testing for vibration sensation at the vagina and clitoris, and stretch sensation at the vagina and introitus, in the third trimester, three and six months postnatal.
Antenatally vibration sensation was reduced but stretch sensation was normal. Postnatally vibration sensation deteriorated whilst stretch sensation initially deteriorated but recovered by six months postnatal to antenatal levels (all p<0.001).
Mode of birth had a significant impact on sensation, with caesarean section appearing neuroprotective, normal vaginal birth resulted in a transient deterioration in sensation that recovered by six months, whilst assisted vaginal delivery was prolonged suggesting persistent neurological impairment (all p<0.015).
Further research is required to study the clinical effect of these changes on pelvic floor dysfunction in the medium and long-term.
... Genital vibratory stimulation may facilitate sexual arousal and orgasm in women with compromised genital sensory thresholds. Genital sensory testing has revealed higher sensation thresholds in women with urinary incontinence and sexual dysfunction (Lowenstein, Gruenwald, Itskovitz-Eldor, Gartman, & Vardi, 2011). Abnormalities in genital sensory testing have been found in about 20% of women with sexual dysfunction (defined by abnormal self-reported FSFI scores) and in women with multiple sclerosis (Esposito et al., 2007;Gruenwald, Lowenstein, Gartman, & Vardi, 2007). ...
Vibration, as provided by a genital vibrator, is commonly regarded as a tool to enhance sexual pleasure and in modern day society falls under the category of a sex toy. However, the vibrator was not originally intended to be a toy, and its benefits reach far beyond that of a plaything. This article is a narrative review of the current evidence regarding the use of vibratory stimulation for the treatment of sexual dysfunction and/or sexual and relationship enhancement. The literature indicates that vibratory stimulation has evidence-based support for the treatment of erectile dysfunction, ejaculatory dysfunction and anorgasmia. Vibratory stimulation is positively correlated with increased sexual desire and overall sexual function. It has also shown benefit for sexual arousal difficulties and pelvic floor dysfunction. Though definitive evidence is lacking, genital vibration is a potential treatment for sexual dysfunction related to a wide variety of sexual health concerns in men and women.
... To identify different types of incontinence, validated questionnaires have been developed and recommended as reproducible clinical research tools. 2 Incontinent women have been reported to present urinary leakage during sexual penetration and orgasm, difficulties reaching orgasm, and less desire, lubrication, and satisfaction. 4 For those women who experience leakage of urine during sexual activity, it has been suggested that UUI and SUI show a stronger association with leaking urine during orgasm and during penetration, respectively. 5 Women's sexuality and sexual function are complex issues, and the role of UI is not completely clear. ...
... To identify different types of incontinence, validated questionnaires have been developed and recommended as reproducible clinical research tools. 2 Incontinent women have been reported to present urinary leakage during sexual penetration and orgasm, difficulties reaching orgasm, and less desire, lubrication, and satisfaction. 4 For those women who experience leakage of urine during sexual activity, it has been suggested that UUI and SUI show a stronger association with leaking urine during orgasm and during penetration, respectively. 5 Women's sexuality and sexual function are complex issues, and the role of UI is not completely clear. ...
Introduction: Urinary incontinence (UI) has been associated with negative effects on women's sexuality. Women's sexuality and sexual function are a complex issue, and the role of UI is not completely clear.
Aim: To assess the impact of UI on female sexual function by comparing this population with a control group of continent women.
Methods: We performed a case-control study from August 2012 to September 2013. We evaluated continent and incontinent women (age range = 30–70 years) for their sexuality.
Main Outcome Measures: All patients were evaluated by anamnesis, physical examination, and self-report quality-of-life questionnaires. In addition, incontinent women underwent a 1-hour pad test. Patients without sexual activity were evaluated for the role of UI in their sexual abstinence. Sexual abstinence was defined as the absence of sexual activity for more than 6 months. All sexually active women completed the self-report Sexuality Quotient–Female Version (SQ-F) questionnaire.
Results: A total of 356 women were included in the study (incontinent, n = 243; continent, n = 113). Sexual abstinence was found in 162 women (45%). Incontinent women presented a higher prevalence (P < .001) of sexual abstinence than their counterparts (129 [53%] and 33 [29.2%], respectively). Age, marital status, and UI were found to be isolated predictive factors for more sexual abstinence in incontinent women. Sexually active women (incontinent, n = 114; continent, n = 80) presented similar demographic data. Despite a similar frequency of sexual activity, incontinent women had less sexual desire, foreplay, harmony with a partner, sexual comfort, and sexual satisfaction than their counterparts. Women with greater urinary leakage during the 1-hour pad test (weight > 11 g) had the worst sexual function (SQ-F) score.
Conclusion: Women with UI were more likely to be sexual abstinent than continent women. Furthermore, women with UI showed less sexual desire, sexual comfort, and sexual satisfaction than their counterparts despite having a similar frequency of sexual activity.
Pelvic organ prolapse, urinary, bowel and sexual dysfunction, collectively called pelvic floor dysfunction (PFD) affects 1 in 3 women and has a significant public health impact. The causes of PFD are not fully understood but involve injury to connective tissue and motor nerve during childbirth. Women with PFD also have sensory nerve impairment, and it is likely this occurs during childbirth, but this has never been investigated. In the current study 150 women underwent quantitative sensory testing for vibration sensation at the vagina and clitoris, and stretch sensation at the vagina and introitus, in the third trimester, 3 and 6 months postnatal. Antenatally vibration sensation was reduced but stretch sensation was normal. Postnatally vibration sensation deteriorated whilst stretch sensation initially deteriorated but recovered by 6 months postnatal to antenatal levels (all p < 0.001). Mode of birth had a significant impact on sensation, with caesarean section appearing neuroprotective, normal vaginal birth resulted in a transient deterioration in sensation that recovered by 6 months, whilst assisted vaginal delivery was prolonged suggesting persistent neurological impairment (all p < 0.015). Further research is required to study the clinical effect of these changes on pelvic floor dysfunction in the medium and long-term.
Introduction
Female Genital Sexual Arousal Disorder (FGSAD) seriously affects women's quality of life and Sexual life, but it still lacks ideal FGSAD animal models for further study.
Aim
To establish a specific model of female genital sexual arousal disorder and explore the mechanisms resulting in FGSAD.
Methods
After delivery, female rats were guided by expansions of the vagina and ovariectomy (VD+OVX, n = 10); in VD group female rats were just extended by the vagina (VD, n = 10), in OVX group female rats were treated with ovariectomy (OVX, n = 10);the remaining had 1 longitudinal incision as sham group(n = 10).
Outcomes
Vaginal dilatation combined with ovariectomy in rats may reflect female genital sexual arousal disorder with high reproducibility and stability.
Results
Vaginal tissue of female rats in OVX group and VD+OVX group showed an increase in blood flow, decrease in muscle content compared to the sham group. The proportion of collagen fiber I/III decreased and the elastic fiber showed significant rupture and fragmentation; Structural reticular integrity was also significantly separated and broken from the muscle fibers. However, there was no significant difference in vaginal blood flow, fibers and vascular between VD group and Sham group. The damage of vaginal tissue in VD+OVX group was more significant than that in OVX and VD groups.
Clinical Translation
We have constructed a specific animal model that can provide clinical insights into the mechanism of FGSAD and serves as a good avenue for further research of its treatment.
Strengths and Limitations
Vaginal dilatation combined with ovariectomy in rats is a specific animal model with high reproducibility and stability, but we do acknowledge the shortcomings and limitation present in our study. Since genital arousal disorder has many different etiologies that impact the vagina, the clitoris and surrounding tissues, there is no “gold standard” model that different models attempt to investigate different etiologies.
Conclusion
The female genital sexual arousal disorder model established by vaginal dilatation combined with ovariectomy is a novel rat model with simple induction conditions, which pathogenic mechanism of female genital sexual arousal disorders maybe connected with the change of VEGF and MMP-9 in vaginal fibromuscular system and microvascular.
Li G, Yu P, Hu Y, et al. Establishment of Rat Model of Female Genital Sexual Arousal Disorder. Sex Med 2022;XX:XXXXXX.
In the 90s a better understanding of the pathophysiology of erectile dysfunction (ED) was formulating [1]. Simultaneously the magnitude and the correlates of male sexual dysfunction were getting in focus [2]. A few years later, oral phosphodiesterase type 5 inhibitors (PDE5i) came to use and along came the development of several objective assessment tools to gauge sexual dysfunction in men [3]. Parallel to these developments, lower urinary tract symptoms (LUTS) were under extensive investigations which resulted in a major shift in diagnosis and treatment. Not before long that the association of LUTS and male sexual dysfunction was clear [4]. Therapies that targeted both were tried [5, 6]. The female sexual dysfunction (FSD) finally reached focus and went along the path of development of objective assessment tools, identifying risk factors and looking at treatment options [7]. The association between a neurologic pathology and each facet of the genitourinary dysfunction is rampant in the literature, albite on a paired basis. The association between a neurologic pathology and either ED, orgasm, ejaculatory dysfunction, LUTS, fertility or FSD was repeatedly reported (Fig. 56.1). On the other hand, the association of LUTS on one hand and either male or female sexual dysfunction was a subject of many reports. There is a paucity of reporting of the association of the three conditions together whether in men or women. The purpose of this review is to shed light on citations that had a clear view of the presence of such association and how it was managed.
Aims:
To explore the role of sensory nerve impairment in women with pelvic organ prolapse, painful bladder syndrome, urinary and fecal incontinence, and sexual dysfunction.
Methods:
Medline and Embase were searched for articles in which sensory testing, either quantitative sensory testing or current perception thresholds, had been used to evaluate women with pelvic organ prolapse, stress and urge urinary incontinence, fecal incontinence and female sexual dysfunction. All search terms were expanded within each database prior to searching.
Results:
Research to date has included small numbers of participants, used poorly matched controls, lacked a systemic sensory examination and applied non-standardized sensory testing techniques. However, the evidence suggests women with pelvic organ prolapse demonstrate sensory dysfunction. The role of sensory impairment in stress urinary incontinence is inconclusive. In women with urge urinary incontinence there is some evidence to suggest it may be urethrally mediated. Women with painful bladder syndrome may have more sensitive nerve endings which are unable to ignore repeated stimuli. Sensory impairment is common in women with sexual dysfunction, typically involving larger nerve fibres. There were no studies evaluating sensory function in women with fecal incontinence.
Conclusion:
Current evidence suggests women with pelvic floor dysfunction demonstrate sensory impairment though the causes remain unclear. Further studies are needed to investigate the different conditions of pelvic floor dysfunction using standardized sensory testing techniques, as well as evaluate the timing and mechanism by which any sensory impairment develops. Neurourol. Urodynam. © 2016 Wiley Periodicals, Inc.
Introduction
Female sexual dysfunction (FSD) is multifactorial, with psychological and organic elements. Genital sensation, an important component of sexual response, has until recently not been subjected to adequate clinical appraisal. During the past 15 years we have performed Quantitative Sensory Testing (QST) to assess genital sensation in healthy women and women with FSD.
Aim
To review available evidence of QST in the investigation of genital sensation in women with FSD.
Methods
We examined data obtained from assessment of genital sensation in normal women and those with different conditions, including multiple sclerosis, pelvic floor disorders, effect of hysterectomy, and vulvar vestibulitis.
Main Outcome Measure
Use of QST for assessment of FSD.
Results
Normograms for healthy women were used to measure parameters during arousal, orgasm, and the refractory phase. Using QST, genital sensation was found to be impaired in women with multiple sclerosis. Clitoral vibratory sensation most significantly correlated with FSD parameters. Women with greater deficit in vibratory sensation encountered more sexual dysfunction. Women with urinary incontinence had a significant decrease in sensitivity to warm, cold, and vibratory thresholds in the anterior vaginal wall and clitoral area. A study comparing women with and without pelvic organ prolapse showed mean thresholds for vibratory and warm stimuli to be significantly higher and mean thresholds for cold stimuli to be significantly lower in the group with prolapse. QST of women undergoing hysterectomy showed a significant decrease in sensation to cold, warm, and vibratory stimuli at the anterior and posterior vaginal wall; clitoral thermal and vibratory sensation thresholds remained unchanged after surgery. In a study of vulvar vestibulitis, patients reported significantly lower heat pain thresholds compared with controls.
Conclusion
QST appears useful for evaluating various gynecologic disorders associated with disturbed sexual function and with multiple sclerosis, which might be accompanied by disturbed genital sensation.
Introduction
Previous studies have reported changes in the sensory functioning of the vagina in women with pelvic floor disorder.
Aim
To evaluate vaginal and clitoral sensation before and after surgery with trans-obturator tape (TVT-O, Ethicon Johnson & Johnson).
Methods
Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina and clitoris 1 day before and 12 ± 4 months after surgery.
Main Outcome Measures
Differences in thresholds to warm, cold, and vibratory sensations at a predetermined anatomic area of the genital region.
Results
Twenty-two women were admitted for midurethral sling surgery, and four were lost to follow-up. For the remaining 18 (mean age = 52 years, range = 37–65), we found a significant sensory decrease at the clitoral region to cold, warm, and vibratory stimuli after surgery. In contrast, in the anterior vaginal wall, there was a significant decrease only to warm stimuli after surgery.
Conclusion
TVT-O can cause sensory loss in the clitoral and anterior vaginal wall region that can be measured and quantified. The effect of such sensory loss on sexual function and quality of sexual life needs further investigation.
Background:
Female sexual dysfunction (FSD) is diagnosed when an impairment in the sexual response cycle is associated with distress in women. The association between obstructive sleep apnea (OSA) and FSD has been poorly investigated with conflicting results.
Aim:
To assess the role of OSA in determining FSD in pre menopausal obese women.
Methods:
Forty-six women underwent standard polysomnography. Data on sexual function and sexual-related distress were obtained using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS). Women with both abnormal FSFI and FSDS scores were classified as having FSD.
Results:
Thirty-one women were classified as having OSA. Fourteen (30.4%) women had both sexual difficulties and sexual distress resulting in FSD; they showed higher values of sleep time spent with SpO(2) <90% (T(90) 16.8 ± 24.4 vs. 3.2 ± 5.2%; p = 0.004). FSD was present in 10 women with OSA (32.2%); in this group T(90) was higher (23.5 ± 26.3) in women with FSD than in those without FSD (4.8 ± 5.8; p = 0.003). In a logistic multiple regression analysis, T(90) was the only factor associated with an increased risk for FSD (odds ratio [OR] 1.07) (confidence interval [CI]) 1.006-1.13]; p = 0.03).
Conclusions:
In premenopausal obese women the presence of FSD is correlated with OSA only when nocturnal hypoxia is present.
Factual presentations of sexual anatomy are required for educational purposes, for clinical and more general communication about sexual matters. To date, unambiguous, accurate and objective images with appropriate labeling to enhance specificity in communication have been lacking.
The aim of this presentation is to provide a comprehensive overview of anatomy of the distal vagina. We aim to simplify the anatomy to reduce the confusion of historical descriptions. In doing so, we aim to avoid sacrificing any of the specific detail. This would aid communication between clinicians, researchers, and the nonclinician regarding this anatomy. OUTCOME MEASURES AND METHODS: This article reviews the historical and current anatomical literature. Systematic dissection and photography, histological study, and magnetic resonance imaging have been used as the basis for this presentation. Digital technology has been used to label, color, and highlight photography to provide clarity and permit diagramatization of photography. No distortion has otherwise been used in presenting images from cadavers or anatomical research.
The anatomy of the distal vagina and surrounding structures is shown and described in detailed. The distal vagina, clitoris, and urethra form an integrated entity covered superficially by the vulval skin and its epithelial features. These parts have a shared vasculature and nerve supply and during sexual stimulation respond as a unit though the responses are not uniform.
Significant progress has been made in the field of female sexual anatomy and its pictorial representation. This may facilitate further progress in the related fields of female sexual health and education.
Introduction. A normal sexual response in the female depends on the integrity of afferent sensory input from the genital region. So far genital sensation has been investigated only during a non-excitatory state, and the sensory physiological changes, which occur during the sexual cycle in this region, are still obscured.
Aim. To investigate the sensory status of the female genital region during sexual arousal and orgasm.
Main Outcome Measures. Genital sensory thresholds measured by Quantitative Sensory Testing (vibratory and thermal) were compared in a non-excitatory vs. excitatory state in normal sexually functioning females.
Methods. Eleven healthy female volunteers were recruited and attended three separate visits. During each session only one anatomical site, either clitoris or vagina was tested for either vibratory or thermal stimuli. A psychophysical method of limits was employed for threshold determination of warm or vibratory stimuli. In each session, all women were tested at baseline, immediately after arousal, after orgasm and three more measurements – 5, 10, and 20 minutes during the recovery state.
Results. A significant decrease in clitoral vibratory sensation threshold was observed between the baseline and the arousal phases (P = 0.003). Comparison of vibratory sensation between baseline and following orgasm at the clitoral and vaginal region showed a significant difference (P < 0.001) for both regions. These changes were not significant for thermal threshold sensation at the clitoral region (P = 0.6).
Conclusions. This is the first time that genital sensation has been measured during the excitatory phase of the female sexual cycle. This normative data may serve as a baseline for further investigations of the sensory input of the genital organs during intercourse in pathological states. Gruenwald I, Lowenstein L, Gartman I, and Vardi Y. Physiological changes in female genital sensation during sexual stimulation. J Sex Med 2007;4:390–394.
Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report.
This report combines the input of members of the Standardization and Terminology Committees of two international organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Appropriate core clinical categories and a subclassification were developed to give an alphanumeric coding to each definition. An extensive process of 15 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).
A terminology report for female pelvic floor dysfunction, encompassing over 250 separate definitions, has been developed. It is clinically based with the six most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific imaging (ultrasound, radiology, and MRI) has been a major addition while appropriate figures have been included to supplement and help clarify the text. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible.
A consensus-based terminology report for female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.
The functions of the lower urinary tract (LUT) to store and periodically release urine are dependent on neural circuits in the brain and spinal cord. This paper reviews the central neural control of micturition and how disruption of this control can lead to bladder overactivity and incontinence.
Neuroanatomic, electrophysiologic, and pharmacologic techniques have provided information about the neural circuitry and the neurotransmitters involved in the central nervous control of voiding. Experimental models of neural injury, including spinal cord transection, cerebral infarction, and localized brain lesions, have been studied to identify the mechanisms contributing to the neurogenic overactive bladder.
Normal storage of urine is dependent on 1) spinal reflex mechanisms that activate sympathetic and somatic pathways to the urethral outlet and 2) tonic inhibitory systems in the brain that suppress the parasympathetic excitatory outflow to the urinary bladder. Voiding is mediated by inhibition of sympathetic-somatic pathways and activation of a spinobulbospinal parasympathetic reflex pathway passing through a micturition center in the rostral pons. Damage to the brain can induce bladder overactivity by reducing suprapontine inhibition. Damage to axonal pathways in the spinal cord leads to the emergence of primitive spinal bladder reflexes triggered by C-fiber bladder afferent neurons. The C-fiber afferent neurotoxin capsaicin, administered intravesically, has been useful in treating certain types of neurogenic bladder overactivity.
The central nervous mechanisms controlling the LUT are organized in the brain and spinal cord as simple on-off switching circuits that are under voluntary control. Damage to central inhibitory pathways or sensitization of peripheral afferent terminals in the bladder can unmask primitive voiding reflexes that trigger bladder overactivity.
Neurologic disorders might be responsible for many cases of female sexual dysfunction. Yet, they are currently undiagnosed because of the lack of measurement tools to assess genital neural function. Therefore, our objective is to provide norms for sensory thresholds in the vagina and clitoris, for a wide range of patient ages.
Vaginal and clitoral warm, cold, and vibratory sensory thresholds were measured in 89 healthy paid volunteers by the method of limits. Normograms were derived from this group of healthy volunteers. An additional 61 patients were also tested, for a total of 150 individuals. Sixty-two individuals (42 healthy volunteers and 20 patients) from the total group were tested twice to provide test-to-test repeatability data across the range of clinical (normal and abnormal) responses.
Normograms are presented, providing age-corrected upper and lower normal values, expressed as 95% confidence limits for warm, cold, and vibratory thresholds. Intertest repeatability is also reported.
Thermal and vibratory thresholds of both the vaginal and clitoral region are clinically feasible, valid, and repeatable. These can be applied as a valuable diagnostic tool to assess neural dysfunction through sensory assessment of the female genitalia.
To investigate the therapeutic effect of resiniferatoxin in patients with chronic spinal cord lesions, as detrusor hyper-reflexia and external sphincter dyssynergia (DESD) are common phenomenon in such patients.
Twenty patients with chronic spinal cord lesions and DESD refractory to anticholinergic treatment were enrolled in a prospective study. They were treated with 30 mL of 10 micro mol/L resiniferatoxin for 30 min. Four types of response were recorded during instillation: type 1, a sustained high-pressure detrusor contraction followed by complete acontractility; type 2, a high-pressure contraction followed by progressively lower contractions; type 3, intermittent high-pressure detrusor contractions throughout the instillation; type 4, intermittent low-pressure detrusor contractions. The changes in clinical symptoms and urodynamics at baseline, during resiniferatoxin instillation and 1 month after treatment were compared.
All patients had DESD and 10 had autonomic dysreflexia; 18 had urinary incontinence and 13 had difficult urination. Continence and/or difficult urination improved in 12 patients, including all five with type 1, four with type 2, two with type 3 and only one with a type 4 response. Four patients became dry during the day and eight had less urgency and fewer incontinence episodes, and a significantly increased voided volume. Of the 13 patients who complained of difficult urination, eight had an improvement either by spontaneous voiding (five) or the Crede manoeuvre to voiding (three). The mean (sd) maximum cystometric capacity increased significantly after treatment, from 102.1 (31.5) to 236.6 (88.6) mL (P < 0.001), but the detrusor pressure showed no significant change, at 55.9 (23.2) to 47.5 (28.1) cmH2O. The external urethral sphincter showed intermittent activity during reflexic detrusor contractions at baseline.
Resiniferatoxin at 10 micro mol/L has a clinical effect on two-thirds of patients with a spinal cord lesion and detrusor hyper-reflexia, but not on the DESD. The initial response to resiniferatoxin instillation might predict a favourable therapeutic outcome.
To evaluate human bladder mucosal sensory function by neuroselective Current Perception Threshold (CPT) measures from healthy and neuropathic bladders.
Eight healthy volunteers and 38 patients with urinary symptoms underwent conventional urodynamic tests including water-filling cystometry and ice water test. Standardized neuroselective CPT measures were obtained from the left index finger and the mucosa of the posterior bladder wall. Three different CPTs were obtained from each test site using a constant alternating current sinusoid waveform electrical stimulus presented at 2000Hz, 250Hz and 5Hz stimulation frequencies, which could selectively reflect the functions of the large myelinated fibers (A-beta-fiber), the small myelinated fibers (A-delta-fiber), and the unmyelinated fibers (C-fiber), respectively.
As the determination of CPT values on the finger skin, the CPT values in the bladder could be determined using the neuroselective measures in all patients but three who had no sensory response (absence of sensation) caused by complete spinal injury. In the 8 patients with detrusor hyperreflexia due to incomplete spinal cord injury (supra-sacral lesion), the bladder CPT value (4.0+/-1.9) at 5Hz was significantly lower (p<0.01) than that in the controls (26.2+/-17.7). In the neurogenic bladders determined to be underactive (n=11, including post pelvic surgery, post infra-sacral level spinal cord injury and diabetes patients), the higher CPT values of bladder mucosal sensory functions were found at 5Hz (p<0.05), 250Hz (p=0.07), and 2000Hz (p<0.05) compared to the controls.
Quantitative neuroselective measurement of CPT values in the human bladder mucosal function was feasible. Hypersensitivity or hyposensitivity of the urinary sensory function could be determined using the CPT values in comparison to control. The quantitative neuroselective estimation of the bladder sensory functions in different types of sensory peripheral nerve fibers may contribute to the appropriate selection of therapeutic strategy in patients with urinary sensory dysfunction.
Vulvar vestibulitis syndrome (VVS) is a common cause of dyspareunia in pre-menopausal women. Previous quantitative sensory test (QST) studies have demonstrated reduced vestibular pain thresholds in these patients. Here we try to find whether QST findings correlate to disease severity. Thirty-five vestibulitis patients, 17 with moderate and 18 with severe disorder, were compared to 22 age matched control women. Tactile and pain thresholds for mechanical pressure and thermal pain were measured at the posterior fourcette. Magnitude estimation of supra-threshold painful stimuli were obtained for mechanical and thermal stimuli, the latter were of tonic and phasic types. Pain thresholds were lower and supra-threshold magnitude estimations were higher in VVS patients, in agreement with disease severity. Cut-off points were defined for results of each test, discriminating between moderate VVS, severe VVS and healthy controls, and allowing calculation of sensitivity and specificity of the various tests. Our findings show that the best discriminative test was mechanical pain threshold obtained by a simple custom made 'spring pressure device'. This test had the highest kappa value (0.82), predicting correctly 88% of all VVS cases and 100% of the severe VVS cases. Supra-threshold pain magnitude estimation for tonic heat stimulation also had a high kappa value (0.73) predicting correctly 82% overall with a 100% correct diagnosis of the control group. QST techniques, both threshold and supra-threshold measurements, seem to be capable of discriminating level of severity of this clinical pain syndrome.
Resiniferatoxin (RTX) is a specific C fiber neurotoxin which produces desensitization. In this study we performed intravesical RTX therapy in patients with idiopathic detrusor overactivity. In addition we measured the current perception threshold of C and A delta fibers before and after treatment to evaluate clinical significance.
The protocol involved an RTX solution (100 ml of 50 nM) instilled in the bladder for 30 minutes. Four men and 6 women 59 to 75 years old were treated. Effects on bladder function were evaluated before and 30 days after treatment by cystometry and Neurometer (Neurotron, Inc., Baltimore, Maryland). Subjective and objective measures included bladder diaries and quality of life before treatment, and 7, 30 and 90 days subsequently.
Of the 10 patients 5 noted improvement and 2 of them became dry. The other 5 patients were considered to have stationary symptoms. Mean maximal cystometric capacity +/- SD increased from 229 +/- 108 ml at baseline to 271 +/- 99.5 ml at 30 days (p = 0.04). The mean number of daily episodes of urinary incontinence decreased from 3.5 +/- 2.2 to 2.0 +/- 1.6 (p = 0.008) at 7 days, to 1.9 +/- 1.6 (p = 0.018) at 30 days and to 2.5 +/- 1.7 (p = 0.018) at 90 days. Mean current perception threshold values of C and A delta fibers did not change significantly, from 46.9 +/- 35.2 to 56.4 +/- 32.1 (p = 0.161) and from 66.9 +/- 31.7 to 66.4 +/- 25.2 (p = 0.952), respectively. However, values of C fibers increased in all patients who showed improvement from 46.2 +/- 33.2 to 64.0 +/- 36.8 (p = 0.043).
Intravesical RTX improved bladder capacity and leak episodes in patients with idiopathic detrusor overactivity. Intravesical RTX is a promising treatment for this condition.
Female sexual dysfunction (FSD) is highly prevalent (45-74%) in multiple sclerosis (MS) patients. Quantitative sensory testing (QST) has recently been used to assess normal neural function of the female genitalia. In this study we used QST for assessment of the genital neural function of female MS patients.
We examined 41 female MS patients aged 21-56, with 10 years median disease duration. Each patient had a neurological examination, and evaluation of sexual function (SF) by both questionnaire and a focused interview. QST was performed at the clitoris and vagina for temperature and vibratory stimuli, by method of limits.
By questionnaire, 25 patients (61%) had FSD; the most common complaints were decreased libido (61%) and orgasmic disturbances (54%). Sensory deficit was very common--significant correlations were found between high sensory thresholds and FSD parameters; the most significant correlation was between clitoral vibratory sensation and orgasmic dysfunction (r = 0.423, P = 0.006). Another interesting significant association was found between cerebellar deficit and orgasmic dysfunction (P = 0.0012).
This study suggests that QST of the genitalia, specifically clitoral vibration, may be a useful test for detecting sexual dysfunction in MS patients, and supports an important role of the cerebellum in SF.
To compare current perception thresholds (CPT) in the urethra and bladder of women with idiopathic overactive bladder to asymptomatic controls.
Women with > or =1 urge urinary incontinence (UUI) episode per week on 7-day diary, seeking treatment for UUI underwent CPT testing using a Neurometer(R) CPT device (Neurotron, Inc., Baltimore, MD). Testing was done in the urethra and bladder at three frequencies 2,000, 250, and 5 Hz corresponding to A-beta, A-delta, and C fibers, respectively. CPT values from the women with UUI were compared to CPT values from a group of control women without lower urinary tract symptoms.
Forty-eight controls without lower urinary tract symptoms and 13 women with UUI were included in the analysis. Women with UUI were significantly older (mean +/- SD age 62 +/- 14 and 44 +/- 15, P < 0.0005) and more likely to be vaginally parous (P = 0.007) than control women. Urethral CPT at 2,000, 250, and 5 Hz were significantly higher in women with UUI than controls, while bladder CPT were not different between groups. Using logistic regression, to control for age and parity, urethral CPT at 5 Hz remained significantly higher in women with UUI than controls (P = 0.013).
Urethral sensation is significantly higher in older women, suggesting sensory neuropathy in the lower urinary tract increases with age and may contribute to the increase in overactive bladder seen with aging. These data reinforce the role of the urethra in lower urinary tract function.