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Micturitional histories and urodynamic studies were performed in 14 patients with syringomyelia. Eleven patients were revealed to have urinary symptoms including difficulty of voiding in 8, urinary retention in 3, nocturnal and diurnal urinary frequency in 3, urinary incontinence in 2, and sense of urgency and enuresis in one. These urinary symptoms appeared after 5.3 years (ranging from 2 months to 13 years) from the occurrence of the neurological symptoms. Urodynamic studies revealed detrusor hyperreflexia in 7, detrusor areflexia in 4, detrusor-sphincter dyssynergia in 4 and uninhibited sphincter relaxation in 2 patients. Analysis of the motor unit potentials of the external sphincter revealed 5 of 6 patients had high amplitude or polyphasic neurogenic changes. Supranuclear as well as nuclear types of parasympathetic and somatic nerve dysfunctions seemed to be responsible for micturitional disturbance in our patients with syringomyelia. During the follow-up period of 2 to 63 months, urinary symptoms gradually improved in 4 of 6 patients after syringosubarachnoid shunts and in 3 of 4 after alpha-adrenoreceptor blocking agents.

In eleven patients with acute disseminated encephalomyelitis (ADEM), micturitional histories taken during the acute stage revealed that nine were in a state of urinary retention, and the other two had urinary frequency and urge incontinence together with difficulty it voiding. After the follow-up period of 3 to 38 months seven of nine patients with retention became able to urinate, but five of them had difficulty in voiding and four of them developed urinary frequency or urge incontinence. Two patients had urinary retention even after 26 and 38 months from the onset. Ten patients underwent urodynamic studies and disclosed detrusor hyperreflexia in six, low compliance bladder in two, atonic cystometrogram in one and detrusor-sphincter dyssynergia in two patients. Motor unit analysis of the externa sphincter revealed polyphasic neurogenic changes in one of four patients. The results were compared with our previous findings it multiple sclerosis (MS), and we found that micturitional disturbance in ADEM seemed to be as common and as severe as in MS Supranuclear as well as nuclear types of pelvic and pudendal nerve dysfunction seemed to be responsible for micturitional disturbance it our patients with ADEM. Micturitional disturbance seemed to be related to the pyramidal tract involvement, and probably reflecting the severity of spinal cord lesions.

In ten patients with acute transverse myelitis (ATM), seven patients had urinary retention, and the other three patients had difficulty in voiding within 1 month from the onset of the disease. Five of the patients with retention became able to urinate. After the mean follow-up period of 40 months, nine still had urinary symptoms including difficulty in voiding in five and urinary frequency, urgency and incontinence in four patients. Four patients had urinary disturbance as the sole sequel of ATM. Urodynamic studies performed on nine patients revealed that all of the three patients with the urgent incontinence had detrusor hyperreflexia, all of the four patients with retention had an areflexic cystometrogram as well as sphincter hyperreflexia, and three of five patients with voiding difficulty had detrusor-sphincter dyssynergia. An areflexic cystometrogram tended to change to a low compliance bladder, followed by detrusor hyperreflexia or a normal cystometrogram. Analysis of the motor unit potentials of the external sphincter revealed that two of the three patients had high amplitude or polyphasic neurogenic changes. Supranuclear as well as nuclear types of parasympathetic and somatic nerve dysfunctions seemed to be responsible for micturition disturbance in our patients with ATM.

We describe a 68-year-old female patient with Parkinson's disease of 10 years' duration who had latently kyphosis and compression fractures of lumbar vertebrae, and had suffered from fractures by falls 4 times in the past three years. Twenty years ago the patient had a subtotal gastrectomy because of peptic ulcer. Causal factors of repeated fractures in this patient are speculated to be (1) Parkinson's disease itself, (2) aged female, (3) gastrectomy, and (4) insufficient management of exercise and fall prevention.

We identified factors that predict the disappearance of the triad of symptoms (gait disturbance, cognitive impairment and urinary incontinence) of idiopathic normal pressure hydrocephalus (iNPH) following shunt surgery in this study. We classified 71 patients with iNPH into those whose objective symptoms disappeared (disappearance group) or remained (residual group), for each of the triad symptoms 12 months after shunt surgery. Logistic regression analyses were used to identify the predictors of the disappearance of symptoms among 10 variables before shunt surgery (e.g., age, sex, severity of symptoms, Evans index, cerebrospinal fluid (CSF) pressure, CSF stasis on computerized tomographic cisternography, regional cerebral blood flow on single photon emission computed tomography, three kinds of prior diseases). For each of the triad symptoms, mild symptoms before shunt surgery were predictors of the disappearance of the symptom. Young age was also a predictor of the disappearance of gait disturbance. When the analysis was conducted using subscores of the Mini Mental State Examination, a successful visuoconstruction subtest and an absence of hypertension were predictors of the disappearance of cognitive impairment. None of the neuroimaging examinations predicted the disappearance of symptoms after shunt surgery in this study.

Depression and anxiety are common mental illnesses. It is recognized that depression/anxiety causes physical changes, including insomnia, anorexia, and bladder dysfunction. We aimed to delineate bladder dysfunction in patients with depression/anxiety by reviewing the literature. We performed a systematic review of the literature to identify the frequency, lower urinary tract symptoms (LUTS), urodynamic findings, putative underlying pathology, and management of bladder dysfunction in patients with depression/anxiety. From a recent survey of a depression cohort (at a psychiatry clinic), the frequency of bladder dysfunction in depression is lower (up to 25.9%) than that in Parkinson's disease (up to 75%) and stroke (up to 55%), whereas it is significantly higher than that in age-matched controls (around 10%). In both the depression cohort and the psychogenic bladder dysfunction cohort (at a urology clinic), the most common LUTS was overactive bladder (OAB), followed by difficult urination and infrequent voiding. Compared with severe LUTS, urodynamic findings were dissociated; i.e. urodynamic findings were normal except for increased bladder sensation without detrusor overactivity for OAB (50% of all patients), followed by underactive detrusor without post-void residual for difficult urination. The effectiveness of serotonergic or anti-cholinergic medication for ameliorating OAB in the patients awaits further study. In conclusion, although the frequency of LUTS among the depression cohort is not elevated, depression/anxiety is obviously a risk factor for OAB. This finding presumably reflects that the bladder is under emotional control. Amelioration of bladder dysfunction is an important target in treating patients with depression/anxiety.

To describe a case of SCA31 who presented with possible neurogenic voiding dysfunction.A case report.A 73-year-old man with a 5-year history of cerebellar ataxia developed partial urinary retention. His father and a sister had cerebellar ataxia. Brain magnetic resonance imaging revealed cerebellar atrophy, and gene analysis revealed TGGAA repeat prolongation, and he was diagnosed with spinocerebellar ataxia 31. Urodynamics revealed normal bladder filling but a slightly weak detrusor and a post-void residual urine volume of 130 mL, whereas his prostate volume was normal (26 mL). External sphincter electromyography revealed neurogenic change in the motor unit potentials. In order to lessen the post-void residual, hewas started on 15mg/day pilocarpine with benefit. The weak detrusor and sphincter electromyography abnormality indicated involvement of the sacral spinal cord in this disorder.Neurogenic urinary retention in SCA31 can be listed in the clinical differential diagnosis of cerebellar ataxia. However, possible outflow obstruction in men should always be explored.

Urodynamic studies and neurological examinations were performed on 128 patients with cervical myelopathies including 82 with spondylitic myelopathy and 46 with ossification of the posterior longitudinal ligament (OPLL), investigating the location of the paths subserving micturition in the spinal cord. Accurate history taking revealed micturitional symptoms in 95 patients, including irritative symptoms in 61 and obstructive symptoms in 71. Urinary incontinence was noted in 25 and residual urine of over 100 ml or retention was found in 22. Neurological examination revealed disturbed deep sensation in 55, disturbed superficial sensation in 63 and pyramidal signs (weakness, hyperreflexia of legs and Babinski sign) in 96 patients. Urodynamic studies revealed uninhibited contraction in 61 and detrusor-sphincter dyssynergia in 22 patients. Bladder capacity was smaller in patients with Babinski sign (P < 0.05) and in patients with uninhibited contraction (P < 0.001). Uninhibited contraction was more frequent in patients with all three of the above-mentioned pyramidal signs (P < 0.05). Detrusor-sphincter dyssynergia was more frequent in patients with disturbed deep sensation (P < 0.05) and pyramidal signs (P < 0.05, P < 0.0005). From above results and our previous findings in patients with anterior spinal artery syndrome and with tabes dorsalis, it is concluded that the pathway subserving detrusor function seems to be located mainly in the lateral column of the spinal cord. The descending pathway subserving coordination of bladder and urethral sphincter seems to be located mainly in the lateral column, and its ascending pathway seems to be located in the dorsal column. The path subserving urinary sensation seems to be located mainly in the dorsal column of the spinal cord.

Objective: The pathogenesis of female urinary retention is not well known. Hence, we systematically investigated the frequency of diseases that underlie female urinary retention in a urodynamic laboratory.Methods: We analyzed data from 450 consecutive female patients. Data registries included the diagnosis, lower urinary tract symptom questionnaires, urodynamic study results, and neurologic exam observations. Complete urinary retention is defined as mean post-void residual (PVR) urine volume > 100 ml with no voluntary void at all; whereas incomplete urinary retention is defined as mean PVR urine volume > 100 ml after voluntary partial void.Results: Sixty of the 450 female patients visiting our lab (13%) had urinary retention with 4 (6.7%) of these having complete retention and 56 (93.3%) having incomplete retention. The most common underlying disease in these 60 patients was lumbar spondylosis (LS), 38.3% (with 16 patients having LS alone and 7 having LS & diabetic distal polyneuropathy [DPN]), multiple system atrophy (MSA), 18.3%, and DPN, 14.4% (with 2 patients having DPN alone and 7 having LS & DPN), followed by drug-induced retention (e.g., by antidepressants), 8.3%, acute myelitis of possible demyelinating origin, 5.0%, and other etiologies. An underactive detrusor was the major urodynamic findings in those patients.Conclusion: The present study revealed that common etiologies for female urinary retention are neurologic, e.g., an underactive detrusor due to MSA, age-related LS, and lifestyle-related DPN. Therefore LS and DPN, both common diseases, should also become major treatment targets in order to maximize patients’ quality of life.

In 5 patients with multiple system atrophy, administration of 15 mg/day of amezinium metilsulfate, an adrenergic agent, during 6 months for the treatment of postural hypotension exacerbated post-micturition residuals as compared to that before treatment (178 ml versus 113 ml for a change of 37 %, p0.05). Amezinium metilsulfate most probably stimulates both alpha1B-receptors in the vascular wall and alpha1A/D-receptors in the proximal urethra.

A case of sacral herpes zoster infection in a 56-year-old man with the complication of loss of urinary voiding sensation is presented. He had typical herpes zoster eruption on the left S2 dermatome, hypalgesia of the S1-S4 dermatomes, and absence of urinary voiding sensation. There was no other urinary symptom at the first medical examination. Urinary complications associated with herpes zoster are uncommon, but two types, acute cystitis and acute retention, have been recognized. No cases of loss of urinary voiding sensation due to herpes zoster have been reported. In this case, hypalgesia of the sacral dermatomes was mild compared to the marked loss of urethral sensation. This inconsistency is explained by the hypothesis that the number of urethral fibers is very small as compared to that of cutaneous fibers, therefore, urethral sensation would be more severely disturbed than cutaneous sensation.

One of the hallmarks in the pathology of multiple system atrophy (MSA) is neuronal loss in the sacral Onuf’s nucleus11,33,37. Onuf’s nucleus plays a key role in urinary and fecal continence12. Neurons in this nucleus receive not only cortical inputs, but also noradrenergic and serotonergic facilitatory inputs via interneurons from various brainstem structures, including the pontine urine-storage center57,68. External anal sphincter (EAS)electromyography (EMG) is an established method to detect neurogenic change in motor unit potentials (MUP), which mostly reflects denervation and reinnervation of the sphincter muscle30. The significance of the EAS-EMG in MSA has been well known30,69,74. Physiologically, external urethral sphincter (EUS) and EAS share sacral pudendal innervation from Onuf’s nucleus20. In this article, we review the normal physiology and pathophysiology of the lower urinary tract and the lower gastrointestinal tract briefly, the current methods and interpretations of EAS or EUS-EMG, and sphincter EMG in autonomic disorders.

This review article introduces the new concept of vascular incontinence, a disorder of bladder control resulting from cerebral white matter disease (WMD). The concept is based on the original observation in 1999 of a correlation between the severity of leukoareosis or WMD, urinary symptoms, gait disorder and cognitive impairment. Over the last 20 years, the realization that WMD is not a benign incidental finding in the elderly has become generally accepted and several studies have pointed to an association between geriatric syndromes and this type of pathology. The main brunt of WMD is in the frontal regions, a region recognized to be crucial for bladder control. Other disorders should be excluded, both neurological and urological, such as normalpressure hydrocephalus, progressive supranuclear palsy, etc., and prostatic hyperplasia, physical stress incontinence, nocturnal polyuria, etc. Treatment involves management of small vessel disease risk factors and anticholinergic drugs that do not easily penetrate the blood brain barrier to improve bladder control.

Objectives: We reported cases of amnestic mild cognitive impairment (MCI) without the core clinical features of dementia with Lewy bodies (DLB) (dementia and spontaneous parkinsonism) with low uptake in 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy. Methods: During a 3-year period at a university clinic, we had 254 patients with memory complaints; 106 men, 148 women; mean age 72.5 years (48-95 years). In all patients we performed neurologic examination; memory tests including the MMSE, ADAScog, FAB and additional WMS-R; and imaging tests including brain MRI, SPECT and MIBG scintigraphy. Results: The criteria of amnestic MCI were fulfilled in 44 patients; and 13 of them (30%) showed low MIBG uptake. They had the following: uniformly elderly, with an equal sex ratio, have relatively slow progression, preserved general cognitive function (MMSE 24.8/30). In addition to memory impairment, they commonly showed low frontal function by FAB (12.5/18) and some had mild visual hallucination (5). Other than memory disorder, they had autonomic disorder (nocturia in 7, constipation in 2, postural hypotension in one), REM sleep behavioral disorder (in 3) and occipital hypoperfusion by SPECT (in 5). Conclusion: This cohort of multidomain amnestic MCI cases may present with early stage DLB because of the presence of low MIBG uptake. Clinically, they commonly have low FAB, and may have visual hallucination, autonomic and sleep disorders.

article i nfo Objectives: Whereas delayed gastric emptying is believed to be a causative factor for producing delayed-on and motor fluctuation in Parkinson's disease (PD), few studies have directly measured levodopa pharmaco- dynamics and gastric emptying together. In order to determine the relationship, we measured these two pa- rameters in a single PD patients cohort. Methods: Thirty-one patients with PD were enrolled in the study. They were 11 men and 20 women; age, 68.1±7.8 years; disease duration, 4.2±3.8 years; Unified Parkinson's Disease Rating Scale Part 3 Motor Score18.37±8.60;bowelmovementb3timesaweekin20;alltaking301 mg±94 mg/daylevodopa/carbidopa. All patients underwent levodopa pharmacokinetic study and the gastric emptying study using 13 C-octanoic acid expiration breath test. Statistical analysis was performed by Student's t-test and Mann-Whitney's U test. Results: Pharmacokinetic study showed that the plasma levodopa peak was at 2 hours in 42% (13/31 patients) whereas at 1 hour in 58% (18/31 patients), total of 50.7±16.4 min (mean±standard deviation) in all 31 pa- tients. The gastric emptying study showed that Tmax ( 13 C)>60 min was more common in patients with a plas- ma levodopa peak at 2 hours (14/18, 69%) than in those with a plasma levodopa peak at 1 hour (4/13, 22%) (pb0.05), total of 50.7±16.4 min in all 31 patients. Conclusion: We found a significant relationship between levodopa pharmacokinetics and gastric emptying in PD patients, suggesting that delayed gastric emptying is a causative factor for producing delayed-on in PD. There- fore, studies of improved gastric emptying in order to ameliorate delayed-on in PD are warranted.

Limited attention has been paid to the relationship between urinary symptoms or urodynamic findings and motor disorders in Parkinson's disease (PD). We aimed to correlate pressure-flow urodynamic parameters with video-gait analysis parameters in PD. We recruited 41 patients with PD (25 men and 16 women; age, 70.6 ± 8.5 years; HY motor grading: 2 [range, 1-3]; disease duration: 4 years [range, 1-7]; taking levodopa 300 mg/day [range, 100-400]). All patients underwent pressure-flow urodynamics (parameters: first sensation, bladder capacity, detrusor overactivity [noted in 24 patients], and Watts factor [WF]) and video-gait analysis (parameters: time and number of strides for 5-m gait [simple task] and time for timed up and go [complex task]). Statistical analysis was made by Mann-Whitney's U-test for analyzing the relation between detrusor overactivity and gait as well as Spearman's rank-correlation coefficient test for analyzing the relation between the remaining parameters and gait. We found no relation between filling-phase urodynamics (detrusor overactivity, first sensation, and bladder capacity) and video-gait analysis parameters. By contrast, we found a significant relation between voiding-phase urodynamics (WF, reflecting detrusor power) and all three video-gait analysis parameters (reflecting lower-half bradykinesia and loss of postural reflex) in our PD patients (P0.01). The close relation between the WF and motor disorders in the present study suggests that, though clinically mild, a weak detrusor in PD might have a central origin. We should follow postvoid residual volume carefully in PD patients with advanced gait disorder, because postvoid residual volume might increase in such patients.

Sexual dysfunction (erectile dysfunction) is a common non-motor disorder in Parkinson’s disease (PD).In contrast to motor disorder, sexual dysfunction is often not responsive to levodopa treatment. Among brain pathologies, hypothalamic dysfunction is mostly responsible for the sexual dysfunction (decrease in libido and erection) in PD, via altered dopamine-oxytocin pathways, which normally promote libido and erection. Phosphodiesterase inhibitors are used to treat sexual dysfunction in PD. These treatments might be beneficial in maximizing the patients’ quality of life.

‘Vascular incontinence’ is a part of elderly incontinence due to cerebral white matter change (WMC). We studied the relationship between performance on several cognitive tasks and urodynamic detrusor overactivity (DO) in patients with vascular incontinence. We recruited 40 patients with lower urinary tract symptoms due to WMC [20 male, 20 female; mean age 77 years (60–89 years)]. Other neurologic, urologic, and systemic causes of LUT dysfunction were excluded. All patients underwent urodynamics tests and two sets of cognitive tasks, i.e., the Mini-Mental State Examination (MMSE) (general cognitive tasks), and the Frontal Assessment Battery (FAB) (frontal lobe tasks). The most common urinary symptom was urinary urgency (27 patients), followed by urinary incontinence (26) and nocturnal urinary frequency (25). The urodynamic testing revealed DO in 22 patients. The cognitive testing revealed that the patients’ mean MMSE score was 25.8 (range 15–30), and their mean FAB score was 13.6 (4–18). There was no relationship between DO and the total MMSE or FAB score, but our analysis of the relationship between DO and the six subdomains of the FAB (conceptualization, mental flexibility, programming, sensitivity to interference, inhibitory control, and environmental autonomy) revealed a significant relationship between DO and the inhibitory control task (p

The authors reported 2 cases of Hashimoto's ophthalmopathy. These cases presented with no preceding illness; euthyroid state; acute presentation of painful or painless ophthalmoplegia, preferentially affecting the lateral rectus muscles; positive antithyroglobulin/antithyroid peroxidase antibodies and good responses to steroid treatment. Awareness of this atypical form of ophthalmopathy is important, as glucocorticoid treatment results in a significant improvement of this disorder.

Background Urinary dysfunction is common in Parkinson9s disease (PD); however, little is known about urinary dysfunction in early and untreated PD patients. Methods Fifty consecutive untreated PD patients (mean age, 66.7; mean disease duration, 23.6 months; and mean Hoehn & Yahr scale, 1.9) were recruited; those with other conditions that might have influenced urinary function were excluded. Patients were evaluated using a urinary questionnaire and urodynamic studies. Results Sixty-four per cent complained of urinary symptoms (storage, 64.0%; voiding, 28.0%). Urodynamic studies showed abnormal findings in the storage phase in 84%, with detrusor overactivity (DO) and increased bladder sensation without DO in 58.0% and 12.0% of patients, respectively. In the voiding phase, detrusor underactivity, impaired urethral relaxation such as detrusor sphincter dyssynergia, and bladder outlet obstruction were present in 50.0%, 8.0% and 16% of patients, respectively. In patients with both storage and voiding phase abnormalities, DO+detrusor underactivity was the most common finding. Few patients experienced urge incontinence and/or quality-of-life impairment owing to urinary dysfunction; none had low-compliance bladder or abnormal anal-sphincter motor unit potential. These urinary symptoms and urodynamic findings were not correlated with gender, disease severity or motor symptom type. Conclusion Urinary dysfunction, manifested primarily as storage disorders with subclinical voiding disorders and normal anal-sphincter electromyography, occurs in early and untreated PD patients. In cases with severe voiding disorder and/or abnormal anal-sphincter electromyography, other diagnoses should be considered.

To elucidate the pathophysiology of urinary dysfunction in idiopathic normal-pressure hydrocephalus (iNPH) by single-photon emission computed tomography (SPECT) and statistical brain mapping.Urinary symptoms were observed and N-isopropyl-p-[(123)I]-iodoamphetamine (IMP)-SPECT imaging was performed in 97 patients with clinico-radiologically definite iNPH. The patients included 56 men and 41 women; mean age, 74 years. The statistical difference in normalized mean tracer counts was calculated and visualized between patients with urinary dysfunction of severer degrees (grade 2/4) and milder degrees (grade 1/4) according to the urinary subscales of the iNPH grading scales.There was a significant decrease in tracer activity in the right-side-dominant bilateral frontal cortex and the left inferior temporal gyrus in the severe urinary dysfunction group (P0.05). In order to minimize the effects of gait and cognitive dysfunction, we performed similar analysis among subjects with little or no such dysfunction, and obtained the same results (P0.05) as described above.Urinary dysfunction was found to be closely related with right frontal hypoperfusion in iNPH using [(123) I]-IMP SPECT. This right frontal area is one of the critical areas for regulating micturition. While secondary incontinence can result from gait disturbance or dementia, there may also be a neurogenic mechanism underlying urinary dysfunction, which is a significant burden in patients with iNPH and their caregivers.

We investigated the relationship between stroke and cardio-ankle vascular stiffness index (CAVI), a novel noninvasive measure of vascular stiffness.Eighty-five patients with cerebrovascular disease who underwent CAVI were enrolled in the current study. They were 63 men and 22 women with a mean age of 70.0 ± 10.8 years. They were divided into 4 groups according to neurologic abnormalities and magnetic resonance imaging (MRI) findings: 12 with transient ischemic attack (TIA), 26 with white matter ischemic lesions (WMLs), 17 with large artery atherosclerosis, and 30 with small vessel occlusion. Eight hundred fifty-four healthy patients (487 men and 367 women; mean age 65.1 ± 9.4 years) served as controls. The results were stratified by gender and age and statistically analyzed using the Fisher, Bonferroni-Dunn, and Scheffe tests.The average of CAVI was as follows: control males 60 to 69 years of age, 9.05 ± 0.82 (as a representative value); TIA, 9.3 ± 1.5; WML, 10.3 ± 1.3; large artery atherosclerosis, 10.2 ± 1.2; and small vessel occlusion, 10.0 ± 1.6, respectively. The difference in CAVI between each group and age- and gender-matched controls was 0.492 for TIA (no statistical significance); WML, 0.733 (P.001, and P = .002 Scheffe); large artery atherosclerosis, 0.838 (P.001, and P = .005 Scheffe); and small vessel occlusion, 1.034 (P.001), respectively. Linear regression analysis of CAVI and plaque score revealed a significant relationship in patients with ischemic cerebrovascular disease (P.05).Compared with healthy control subjects, CAVI is statistically greater in patients with ischemic cerebrovascular diseases, particularly with WML, large artery atherosclerosis, and small vessel occlusion, but not in patients with TIA. CAVI had a clear relationship with carotid ultrasound plaque score. It appears that CAVI is a simple and noninvasive test for indicating atherosclerosis in patients with stroke.

Systemic dehydration and diffuse central nervous system signs without any other illness is referred to as dehydration encephalopathy (DE). However, the incidence of DE at emergency units remains uncertain. We investigated the incidence of DE among persons with disturbed consciousness who visited the emergency unit. We reviewed the medical case records of the emergency unit at our university hospital during a 6-month period. Among them, 132 patients presented with disturbed consciousness as the sole initial manifestation on arrival. They were 75 men, 47 women, mean age 68 years (16-95 years). After carefully excluding other etiologies, the incidence of DE was 2% among all persons in the emergency unit and 4% among persons older than 68 years.In conclusion, the incidence of DE in our emergency unit was not common. Nevertheless, recognition of DE is extremely important in order to avoid unnecessary medication in elderly subjects.

Detailed micturitional histories were taken from nine patients with progressive supranuclear palsy (PSP), and eight of them (89%) had micturitional symptoms including urinary incontinence in seven. Urodynamic studies were performed in six patients and the results were as follows. Three had residual urine of 100 ml on average. Four had detrusor hyperreflexia and one had a low compliance cystometrogram. One had detrusor-sphincter dyssynergia. Motor unit analysis of external sphincter was performed in four patients and two had neurogenic changes. The results were compared with our previous findings in Parkinson's disease and in striato-nigral degeneration (SND), and we found that a severe degree of micturitional disturbance in PSP seems to be as common as in SND, especially in the urinary storage phase, and more frequent than in Parkinson's disease. Supranuclear types of pelvic and pudendal nerve dysfunctions seemed to be mainly responsible for micturitional disturbance in PSP.

Detailed micturitional histories and urodynamic studies were conducted to investigate the micturitional disturbance in multiple system atrophy (MSA). Eighty-six patients with MSA comprised of 14 with striatonigral degeneration (SND), 42 with olivopontocerebellar atrophy (OPCA) and 30 with Shy-Drager syndrome (SDS). The results were as follows. Micturitional symptoms were noted in over 90% of patients with each type of MSA. Dominant symptoms were irritative ones in SND and OPCA, and a combination of irritative and obstructive ones in SDS. Micturitional symptoms in SDS appeared earlier than those in SND or OPCA. The degree of micturitional disturbance was severer in SDS than in SND or OPCA. Micturitional disturbance tended to become worse as the disease progressed. The responsible sites of lesions of micturitional disturbance seemed to be supra- as well as infranuclear lesions of the pelvic and pudendal nerves in MSA. Infranuclear lesions were more prominent in SDS than in SND or OPCA. Follow-up studies of some of the patients with SDS and OPCA suggested that the responsible sites of pelvic nerve lesions changed from supra- to infranuclear lesions during the course of disease.

To evaluate the efficacy of extended-release (ER) tolterodine 4mg/day for the treatment of neurogenic detrusor overactivity (NDO) and/or low-compliance bladder by assessing urodynamic parameters.Forty-six patients (25 male, 21 female; mean age 57.6±20.7years) with NDO (n=39) and/or low-compliance bladder (n=7) were included in this 12-week single-arm study. Twenty-one patients (46%) were on clean intermittent catheterization and other patients could void on their own. A video urodynamic study was performed before and at 3 months after treatment. Changes in Overactive Bladder Symptom Score (OABSS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and King's Health Questionnaire (KHQ) as well as changes in number of voids, amount of each void, and number of leaks in 24h according to the 3-day voiding diary were also evaluated before treatment and at weeks 4 and 12 after treatment.Bladder capacity at first sensation and maximum cystometric capacity increased significantly, by an average of 36.8mL (P=0.0402) and 82.3mL (P0.0001), respectively. Maximum cystometric capacity increased by more than 50mL in 19 patients (49%) following treatment. Detrusor overactivity disappeared in three of 32 patients (9%), bladder capacity at first involuntary contraction increased significantly (P=0.0009), and amplitude of detrusor overactivity decreased significantly (P=0.0025). In patients with low-compliance bladder, bladder compliance increased significantly (P=0.0156). Overactive bladder symptom score, International Consultation on Incontinence Questionnaire-Short Form score, number of voids (per 24h and night-time), number of urgency episodes in 24h, number and amount of leaks in 24h, and amount of mean and maximum voided volumes all decreased significantly after treatment.Tolterodine is effective and well tolerated for the treatment of NDO and/or low-compliance bladder in patients with neurogenic bladder.

A 70-year-old woman developed paraneoplastic cerebellar degeneration (PCD) due to P/Q-type and N-type voltage-gated calcium channel antibodies and small cell lung cancer, the main clinical manifestations of which were severe positioning vertigo and vomiting. Loss of the visual suppression of caloric nystagmus, spontaneous downbeat nystagmus, periodic alternating nystagmus, and positioning vertigo in our patient most probably corresponds to the cerebellar flocculus/paraflocculus lesion caused by PCD.

Gastrointestinal tract (GIT) dysfunction is common in Parkinson's disease (PD) patients. However, it remains unclear whether levodopa affects GIT function in PD.To perform an open study of levodopa's effects on anorectal constipation in de novo PD patients by the quantitative lower-gastrointestinal autonomic test (QL-GAT).Nineteen unselected de novo PD patients (10 men, 9 women; mean age, 66 years; mean duration of the disease, 2.2 years) were recruited for the study. Eighteen of the patients reported constipation. These patients were treated with 200/20 mg b.i.d. of levodopa/carbidopa for 3 months. Pre- and post-treatment, objective parameters in the QL-GAT that comprised the colonic transit time (CTT) and rectoanal videomanometry were obtained.Levodopa was well tolerated by all patients. There was a trend toward subjective improvements in bowel frequency and difficulty defecating. Levodopa did not significantly change CTT of the total colon or any segment of the colon. During rectal filling, levodopa significantly lessened the first sensation (p 0.05). It also tended to augment the amplitude of spontaneous phasic rectal contraction (not statistically significant). During defecation, levodopa significantly lessened the amplitude in paradoxical sphincter contraction upon defecation (PSD) (p 0.01). It also tended to augment the amplitude of rectal contraction and lessen the amplitude of abdominal strain (not statistically significant). Overall, levodopa significantly lessened post-defecation residuals (p 0.05).The QL-GAT in the present study showed for the first time that levodopa augmented rectal contraction, lessened PSD, and thereby ameliorated anorectal constipation in de novo PD patients.

Although the hippocampus has not typically been identified as part of the language and aphasia circuit, recent evidence suggests that the hippocampus is closely related to naming, word priming, and anomic aphasia. A 59-year old woman with limbic encephalitis of possible autoimmune etiology, after recovery of consciousness, presented with severe memory impairment in both anterograde and retrograde modalities, episodes of fear, hallucination and convulsion, and transient fluent, phonemic paraphasia, together with small sharp waves diffusely by EEG. Brain MRI revealed bilateral symmetric, discrete lesions in the body to the infundibulum of the hippocampus. The transient phonemic paraphasia noted in our patient may have been a result of primary damage in the hippocampus and its fiber connection to the Wernicke’s area or secondary partial status epilepticus that might have originated in the hippocampus.

Bladder dysfunction (urinary urgency/frequency) and sexual dysfunction (erectile dysfunction) are common nonmotor disorders in Parkinson's disease (PD). In contrast to motor disorders, genitourinary autonomic dysfunctions are often nonresponsive to levodopa treatment. The brain pathology causing the bladder dysfunction (appearance of overactivity) involves an altered dopamine-basal ganglia circuit, which normally suppresses the micturition reflex. By contrast, hypothalamic dysfunction is mostly responsible for the sexual dysfunction (decrease in libido and erection) in PD, via altered dopamine-oxytocin pathways, which normally promote libido and erection. The pathophysiology of the genitourinary dysfunction in PD differs from that in multiple system atrophy; therefore, it might aid in differential diagnosis. Anticholinergic agents are used to treat bladder dysfunction in PD, although these drugs should be used with caution particularly in elderly patients who have cognitive decline. Phosphodiesterase inhibitors are used to treat sexual dysfunction in PD. These treatments might be beneficial in maximizing the patients' quality of life.

We report a case of a 62-year-old Japanese-Australian woman with progressive supranuclear palsy (PSP) who presented with prominent urinary retention, neurogenic changes in sphincter electromyography, and obstructive sleep apnea syndrome. Urodynamic study revealed a combination of detrusor overactivity during filling and underactivity during voiding. All these non-motor symptoms in PSP mimicked those of multiple system atrophy.

Pathogenesis of reduced or increased bladder sensation is not well known. Hence, we systematically investigated the frequency of reduced or increased bladder sensation in neurologic/mental diseases.We analyzed 911 patients who were referred from within our hospital. Data registries included a diagnosis, a lower urinary tract symptom questionnaire, a urodynamic study, and neurological examinations. Reduced bladder sensation is defined as bladder volume at the first sensation300 ml. Increased bladder sensation is defined as bladder volume at the first sensation100 ml. These patients were stratified into those with and without DO.Neuropathies are the most common cause of reduced bladder sensation (33.3-43.8% in diabetic neuropathy, etc.). Myelopathies are the second most common cause (17.4-25.0% in multiple sclerosis, etc.). Less common is brain diseases (9.6% in multiple system atrophy, etc.). In contrast, myelopathies are the most common cause of increased bladder sensation without DO (25.0-40.0% in spinal forms of systemic lupus erythematosus, Sjogren's syndrome, etc.). Neuropathies are the second most common (17.3-22.2% in post-pelvic organ surgery, diabetic neuropathy, etc.). Less common is brain/mental diseases (20.0% in psychogenic bladder dysfunction, 8.1% in Parkinson's disease, etc.).The present study revealed that neuropathies are the most common cause of reduced bladder sensation in neurologic/mental diseases. Increased bladder sensation without DO occurs mainly in peripheral and central sensory pathway lesions, as well as in basal ganglia lesions and psychogenic bladder dysfunction. Reduced and increased bladder sensation should be a major treatment target for maximizing patients' quality of life.

Introduction This manuscript summarizes the work of Committee 10 on neurologic bladder and bowel of the International Consultation on Incontinence in 2008–2009. As the data are very large the outcome is presented in different manuscripts. This manuscript deals with neurologic fecal incontinence (FI). Methods Through in debt literature review all aspects of neurologic urinary and FI were studied for levels of evidence. Recommendations for diagnosis and treatment, and for future research were made. Results Pathophysiology was summarized for different levels of lesions. For epidemiology, specific diagnostics, conservative treatment, and surgical treatment of neurologic FI levels of evidence and grades of recommendation were made. Conclusions Though data are available that advice and guide in the management of FI in neurologic patients, not many data are with a high level of evidence or high grade of recommendation. More and well-structured research is needed. Neurourol. Urodynam. 29: 207–212, 2010. © 2009 Wiley-Liss, Inc.

We report a 34-year-old woman who, soon after a caesarian delivery with anesthesia by intrathecal bupivacaine hydrochloride injection, developed severe headache and high fever. Whereas C-reactive protein in the serum was normal, the cerebrospinal fluid (CSF) examination showed an increase in cell count (3,040/mm(3); mostly polymorphonuclear cells) and total protein (401 mg/dl), but only mildly decreased glucose content. No organisms were found by CSF staining and culture. Brain MRI scans were normal. Within 10 days after onset, her clinical conditions and CSF returned to normal. Considering previous reports, intrathecal bupivacaine hydrochloride seemed to be the most likely culprit for the development of chemical meningitis in our case.

The forebrain is one of the important suprapontine micturition centres. Previous studies have shown that electrical stimulation of the frontal lobe and the anterior cingulate gyrus elicited either inhibition or facilitation of bladder contraction. Patients with frontal lobe tumours and aneurysms showed micturition disorders. Functional brain imaging studies showed that several parts of the forebrain are activated during bladder filling. We aimed to examine neuronal activities of forebrain structures with respect to bladder contraction in cats. In 14 adult male cats under ketamine anaesthesia in which a spontaneous isovolumetric bladder-contraction/relaxation cycle had been generated, we carried out extracellular single-unit recording in forebrain with respect to the contraction/relaxation cycles in the bladder. We recorded 112 neurons that were related to the bladder-contraction/relaxation cycles. Ninety-four neurons were found to be tonically activated during the bladder-relaxation phase, whereas the remaining 18 neurons were tonically activated during the bladder-contraction phase. Both types of neuron were widely distributed around the cruciate sulcus. Most were located medially (medial and superior frontal gyrus) and the rest were located laterally (middle and inferior frontal gyrus). Neurons recorded in forebrain structures were activated with respect to the contraction/relaxation cycles in the bladder. Forebrain structures may have a significant role in regulating bladder contraction in cats.

To evaluate the effects of bromocriptine on bladder function in Parkinson's disease (PD) patients and compare these effects with those of (L-dopa). We recruited 8 patients with PD. Urodynamic study (UDS) was performed before and 1 hour after administering 100 mg L-dopa/decarboxylase inhibitor (DCI) and 2.5 hours after administering 7.5 mg bromocriptine. After the bromocriptine administration, urinary urgency aggravated. UDS revealed a decreased bladder volume at which detrusor overactivity (DO) was initiated, a decreased bladder volume at first sensation of bladder filling (FSV) (P0.05), an increased maximum Watts Factor value (WFmax) (detrusor contractility), a decreased Abrams-Griffiths (AG) number (urethral obstruction), and a decreased postvoid residual (PVR) (P0.01). Similarly, after the L-dopa administration, urinary urgency aggravated. UDS revealed an aggravated DO (P0.05), a decreased FSV and bladder capacity (P0.01, 0.05), an increased WFmax (P0.05), an increased AG number, and a decreased PVR (P0.01). A single dose of bromocriptine proved to exacerbate urinary urgency and DO in the storage phase, and improve bladder emptying through increased detrusor contractility and decreased bladder outlet obstruction, within hours. With the exception of bladder outlet obstruction, these effects of bromocriptine are similar to the effects of L-dopa, albeit slightly less pronounced.

Multiple system atrophy (MSA) is a neurodegenerative disease characterized clinically by any combination of autonomic, cerebellar, and extrapyramidal symptoms. Autonomic symptoms are usually severe, and urinary symptoms are one of the cardinal features of MSA. Bowel dysfunction and sexual dysfunction are also common in MSA. Quality of life (QOL) in patients with MSA is severely impaired by the presence of pelvic organ dysfunction. Therefore, we aimed to examine the prevalence of pelvic organ dysfunction in patients with MSA. We recruited 256 patients with MSA seen at our neurology clinic. The mean age was 62 years. The control group comprised 158 individuals, and the mean age was 52 years. We administered a questionnaire on pelvic organ dysfunction to the MSA and control groups. The questionnaire had sections focusing on the bladder, bowel, and sexual function. Dysfunction, as described in the responses, was evaluated as normal, mild (once a month), moderate (once a week), or severe (once a day). The Mann-Whitney's U-test was used for statistical analysis. When compared with the control group, the prevalence of pelvic organ dysfunction in the MSA group was significantly higher for urinary storage and voiding dysfunction, bowel dysfunction, and sexual dysfunction. QOL in the MSA group was therefore significantly impaired because of urinary dysfunction (70%, 76%), bowel dysfunction (40% of the men), and sexual dysfunction (26%, 45%). Pelvic organ dysfunction is common in MSA, and QOL is severely impaired in patients with MSA.

We report a 33-year-old woman who had aseptic meningitis alone, without any other systemic manifestations, due to Behcet’s disease. Behcet’s disease should be listed as a differential diagnosis of acute aseptic meningitis because, in acute aseptic meningitis caused by Behcet’s disease, early treatment with corticosteroids could ameliorate this disorder.

Guillain-Barre syndrome (GBS)-complicating pregnancy is rare; and it is generally believed that it carries a high maternal risk. We reported a case of good maternal and fetal outcomes of predominantly sensory GBS (generalized pain and numbness, mild deep sensory ataxia, positive serum IgM anti-GalNAcGD1a antibody)-complicating pregnancy after intravenous immunoglobulin treatment.

Urinary incontinence is common in patients with dementia, and is more prevalent in demented than in non-demented older individuals. Neurogenic incontinence is common in multiple cerebral infarction and dementia with Lewy bodies, and in both diseases walking difficulty and falls are common. In contrast, functional incontinence is common in Alzheimer's disease due to cognitive disability and decreased motivation. Central cholinergic stimulation is the mainstay in the treatment of cognitive decline. In contrast, to date, the use of anticholinergic medications for detrusor overactivity in the elderly is still under consideration, since anticholinergic drugs may lead to undesirable events particularly in the central nervous system, although many studies have used severely demented cases. In the future, studies seeking treatment regimens for an elderly individual with both dementia and urinary dysfunction are warranted.

Urinary incontinence (UI) is a significant burden in the elderly and their caregivers when assessed by quality-of-life measures, early institutionalization, or health economics. UI is well known as a clinical triad for the diagnosis of normal pressure hydrocephalus (NPH). However, other than UI, NPH patients commonly have urinary urgency/frequency (overactive bladder: OAB), and less commonly, voiding difficulty. Fourteen percent of the patients (either women or men) have post-void residual100 ml. The most common urodynamic abnormality is detrusor overactivity (DO), which was noted in 95% of patients. The underlying pathophysiology for OAB/DO in patients with NPH seems to be decreased cerebral blood flow in the right frontal cortex, and to a lesser extent, altered basal ganglia function. Functional UI can overlap the OAB/DO due secondary to impaired cognition/initiative, immobility, or disturbed consciousness in this disorder.