Urinary complaints are common in Multiple Sclerosis (MS), representing a large source of morbidity and financial burden for these patients. These issues can be complex and difficult to manage for the care provider. As new treatments develop, it is important to have a structured but flexible approach to the diagnosis and treatment of urinary symptoms. In this article we review the pathophysiology, symptoms, work up, and management options for the bladder in MS.

INTRODUCTION:Urethral/bladder outlet obstruction (BOO) is a recognized complication after most surgical procedures for stress urinary incontinence. The mechanisms involved are thought to be related to an overcorrection of the urethra (by kinking and/or compressing the urethra) or excessive scar formation between the pubis and urethra. The recommended treatment is usually surgical that aims to free up the obstructed urethra (urethrolysis). For retropubic bladder neck suspension (BNS), robotic-assisted surgery offers a less invasive alternative to classical abdominal approach. We report methods and results of performing robotic-assisted urethrolysis in patients with urethral obstruction after Burch colposuspension.PATIENTS AND METHODS:Six patients presented with voiding difficulties and urinary irritative symptoms after an abdominal hysterectomy and Burch colposuspension. BOO was diagnosed based on history, presenting symptoms, and urodynamic findings, including the maximum flow rate (Qmax) of ≤12 mL/second and detrusor pressure at maximum flow (PdetQmax) of ≥20 cmH2O. Patients underwent robotic-assisted urethrolysis, which consisted of the usual robotic exposure of the abdominal cavity, access to the space of Retzius, removal of Burch sutures, and hypermobilization of the urethra. The intraoperative and postoperative complications, recovery time, and outcome of the procedure to successfully address the patients' symptoms were reviewed and herein reported.RESULTS:Postoperatively, five of the six patients had complete resolution of the obstructive and irritative symptoms. All had improvement of the postvoid residual volume with a median of 46.5 mL (range 0-176 mL). Postoperatively, urodynamic studies were repeated in two patients and PdetQmax decreased from 39 cmH2O before surgery to 21 cmH2O after urethrolysis and from 31 to 21 cmH2O, respectively. Qmax increased from 0 to 17 mL/second and from 6 to 10 mL/second, respectively.CONCLUSIONS:Robotic-assisted urethrolysis is a feasible and attractive minimally invasive procedure to treat BOO after retropubic BNS.

Over the last 50 years, botulinum toxin has been transformed from a cause of life-threatening disease to an effective medical therapy. It has been used in a variety of specialties for different indications, significantly improving patient quality of life. A recent growing body of evidence suggests that intra-detrusor injection of botulinum toxin may have beneficial effects in patients with medication refractory detrusor overactivity and may offer a new minimally invasive alternative to patients with severe overactive bladder symptoms. To review current data regarding the effects of botulinum toxin in patients with overactive bladder, a MEDLINE(®)/PubMed(®) literature search was carried out. The mechanism of action, clinical usage, adverse effects, and treatment efficacy were reviewed and the results are presented in this paper.

The authors wish to include the following acknowledgment inadvertently omitted from the original manuscript: The NARCOMS Registry is supported in part by the Consortium of Multiple Sclerosis Centers (CMSC) and its Foundation. The authors would like to apologise for any inconvenience caused. Sexual dysfunction in patients with multiple sclerosisMultiple Sclerosis and Related DisordersVol. 2Issue 2PreviewSexual dysfunction (SD) is a common complaint in female and male patients with multiple sclerosis (MS) and can arise at anytime during the course of the disease even in patients with low disability. Increasing neurological and physical impairment, psychological factors, and medication side effects are thought to increase rates of SD. Full-Text PDF

Background: Sexual dysfunction (SD) is a common complaint in female and male patients with multiple sclerosis (MS) and can arise at anytime during the course of the disease even in patients with low disability. Increasing neurological and physical impairment, psychological factors, and medication side effects are thought to increase rates of SD.Objective: To determine the prevalence of various SD symptoms among MS patients, their impact on patient self-reported sexual activity and satisfaction (SAS), and to examine the rates at which symptomatic patients utilize therapies for their complaints.Methods: Results from the Spring, 2006 North American Research Committee on Multiple Sclerosis (NARCOMS) Project were reviewed. Participants were asked to answer the Multiple Sclerosis Intimacy and Sexuality Questionaire-19 (MSISQ-19) and to indicate which symptomatic therapy they used to alleviate SD. Symptoms were grouped as severe (they impacted SAS always or almost always), moderate (occasionally), and mild (never or almost never). Primary end point was the prevalence of SD symptoms and their impact on patient SAS.Results: Of 17,883 surveys mailed, 9861 (55.1%) responses were returned. Of these, 6739 (68.3%) answered the questions on sexuality. Respondents were primarily female (76.7%), Caucasian (87.8%), with average age of 38.4 (+/- 9.6), and time since diagnosis of 13.9 years (+9.3). 38.6% of male subjects and 34.8% of female subjects experienced at least 5 different types of severe symptoms. Also, 14.3% of males and 12.9% of females complained of at least 10 severe symptoms that affected their SAS. The most common severe symptoms were shared by both sexes: too long to achieve orgasm/climax (37.8%), inadequate lubrication/difficult erection (36.5%), less intense or pleasure with orgasm/climax (35.2%), lack of interest or desire (32.1%), problems moving the body (29.1%), less feeling or numbness in genitals (28.8%), feeling less confident (25.5%), and body less attractive (24.8%). The severe symptoms positively correlated with time since diagnosis, Patient Determined Disease Steps Score, bladder disability score, and spasticity score. Few patients with at least one severe symptom used therapies to improve their SD (vibrators 19.1%, phosphodiesterase-5 enzyme inhibitors 14.2%, other medications 0.6%, counseling 4.1%, penile device 1.0%, intracorporeal therapy 0.7%, sex surgery 0.5%, and clitoral device 0.3%).Conclusion: SD in patients with MS is multifactorial and very similar in men and women. Despite increasing therapeutic options, many patients with MS do not seek treatment for their SD complaints. It is very important for the physicians caring for patients with MS to initiate discussion of potential SD to allow earlier diagnosis and treatment. (C) 2012 Elsevier B.V. All rights reserved.

In this retrospective, matched-paired study, yeast in the embryo culture medium was associated with a trend toward decreased developmental competency that was more pronounced when observed early in culture. Because live births occurred after transfer of embryos in the yeast-contaminated group, we concluded that yeast contamination is not a reason to cancel embryo transfer (ET).

The hypothesis was tested that the medium used to culture embryos affects the concentration of human chorionic gonadotrophin (HCG) early in pregnancy. The value of these concentrations in predicting successful outcome was also assessed for each medium studied. Patients undergoing IVF between January 1998 and December 2004 and having a day 3 embryo transfer were stratified into one of four groups according to the medium in which their embryos were cultured (P1, IVF500, G1.2, and G1.3). Using receiver operating characteristic (ROC) curve analysis, cut-off values for serum HCG concentrations on day 15 after embryo transfer were calculated for optimal discrimination between cycles resulting in implantation failure and success for each medium. Cut-off points were chosen to maximize sensitivity and specificity. For viable singleton pregnancies, mean HCG concentrations were greater for G1.3 and lower for IVF500 compared with the other media. Discriminatory HCG cut-off concentrations for predicting implantation success were lowest for IVF500, intermediate for P1 and G1.2 and highest for G1.3. The data support the hypothesis that the medium used to culture embryos significantly affects the concentrations of HCG early in pregnancy. Furthermore, when using HCG cut-off concentrations to assess pregnancy outcome, medium type should be taken into consideration.

Objective: To determine whether increasing the number of embryos transferred beyond five increases pregnancy 3 rates in women aged > 40 years:Design: Retrospective analysis of cycles performed between January 1998 and July 2003:Setting: University-affiliated teaching hospital.Patient(s): Women aged > 40 years undergoing a fresh cycle with a day-3 ET (n = 863).Intervention(s): None:Main Outcome Measure(s): Pregnancy; chemical pregnancy, miscarriage rates, umber of viable fetuses at 12 weeks' gestation, live birth rates, and number of babies delivered.Result(s): Compared with patients with fewer than five embryos transferred, those having five or more embryos transferred had significantly increased pregnancy rates and live birth rates, more viable fetuses at 1 2 weeks, and significantly decreased miscarriage rates. None of these outcome variables differed between the five-embryo and more-than-five-embryo groups. There were no differences in outcome when only five embryos were transferred, regardless of whether five or more than five embryos were available. The number of embryos transferred did not significantly influence multiple birth rates.Conclusion(s): The present study demonstrates that in women aged > 40 years, five embryos is the optimum number to transfer, and transferring more than five does not confer any additional benefit to clinical outcome.

Patients undergoing IVF, with or without intracytoplasmic sperm injection, were treated with either recombinant human FSH or urine-derived FSH. Response to ovarian stimulation was monitored by ultrasound examinations and measurement of serum oestradiol concentrations. To define any differences in embryo quality and hence assisted reproductive technology success rates, a retrospective analysis of 811 recombinant FSH versus 555 urinary FSH cycles was undertaken. Embryo quality was assessed as embryo cell number and degree of fragmentation. Implantation and ongoing pregnancy rates were also compared. Use of recombinant FSH resulted in a higher percentage of mature oocytes, improved embryo cleavage, with more embryos available for freezing and higher implantation rates compared with urinary FSH. Oocyte and embryo quality were superior when recombinant FSH was used for ovarian stimulation compared with urinary FSH.