Bulbocavernosus Reflex Research Articles

Pelvic floor electrophysiology in spinal cord injury.

The study aimed to investigate sacral peripheral nerve function and continuity of pudendal nerve in patients with chronic spinal cord injury (SCI) using pelvic floor electrophysiological tests. Twelve patients with low cervical or thoracic SCI were prospectively included. Quantitative external anal sphincter (EAS) muscle electromyography (EMG), pudendal nerve terminal motor latency (PNTML) testing, bulbocavernosus reflex (BCR) testing and pudendal short-latency somatosensory-evoked potential (SEP) measurement were performed. In EAS muscle EMG, two patients had abnormal increased spontaneous activity and seven prolonged motor unit potential duration. PNTML was normal in 10 patients. BCR was present with normal latency in 11 patients and with prolonged latency in one. The second component of BCR could be recorded in four patients. SEPs showed absent cortical responses in 11 patients and normal latency in one. Pudendal nerve and sacral lower motor neuron involvement are significantly associated with chronic SCI, most prominently in EAS muscle EMG. The frequent finding of normal PNTML latencies supports earlier concerns on the utility of this test; however, BCR and pudendal SEPs may have clinical relevance. As intact peripheral nerves including pudendal nerve are essential for efficient supportive therapies, pelvic floor electrophysiological testing prior to these interventions is highly recommended.

Bulbocavernosus Reflex Test for Diagnosis of Pudendal Nerve Injury in Female Patients with Diabetic Neurogenic Bladder.

The study was designed to investigate the clinical application and significance of the bulbocavernosus reflex (BCR) test for diagnosing diabetic neurogenic bladder (DNB) in female subjects. In this study, 68 female patients with DNB and 40 female normal controls were subjected to a nerve conduction study (NCS) of all four limbs and the BCR test. The data were analyzed and compared, and the corresponding diagnostic sensitivities were discussed. Mean BCR latency for female DNB patients was significantly prolonged, compared to that of the control group, suggesting pudendal nerve injuries in female DNB patients. Moreover, DNB patients were categorized according to the diabetes course. Compared to that of Group A (diabetes course < 5 y), the mean BCR latency was significantly prolonged in Group B (diabetes course between 5 and 10 y) and then further prolonged in Group C (diabetes course > 10 y), which were all longer than the control group. Furthermore, compared with that of the controls, the mean BCR latency was prolonged in DNB patients with or without NCS abnormalities in limbs. Nevertheless, no significant difference was observed in BCR latency between DNB patients with and without NCS abnormalities. Significantly increasing trends were also observed in the NCS and BCR abnormality rates along with increased diabetes course. Most importantly, compared with the NCS of limbs, the BCR test was more sensitive in diagnosing DNB in the female subjects. Overall, our findings suggest that the BCR test would help to assess the pudendal nerve injury in female DNB patients, which might be a potential diagnostic tool in the clinic.

Poster 258 Preserved Bulbocavernosus Reflex in a Patient with Tethered Cord Syndrome: A Case Report

Poster 258 Preserved Bulbocavernosus Reflex in a Patient with Tethered Cord Syndrome: A Case Report

Relationship of Bladder Function with Toe Position Sense, Neurological Level, Lesion Severity, and Bulbocavernosus Reflex in Patients with Spinal Cord Injury

Relationship of Bladder Function with Toe Position Sense, Neurological Level, Lesion Severity, and Bulbocavernosus Reflex in Patients with Spinal Cord Injury

Premature ejaculation associated with lumbosacral lesions.

Retrospective study. Spinal cord injuries are usually associated with anejaculation, but few premature ejaculations (PE) are described in lumbosacral lesions. The objective of the study is to analyze the retrospective files of patients with lumbosacral lesions to explore whether PE is systematic, and which type of lesions (conus teminalis, epiconal, cauda equina) is associated with these PE. Standard sexological consultations from 34 men with L5-S4 lesions were analyzed including questions on psychogenic and reflexogenic erection, and ejaculation. Medical assessment included bulbocavernosus, anal, and cremasteric reflexes and urodynamics. Thirty one (31/33) patients maintained natural ejaculations, but 18 complained of PE and five of spontaneous ejaculations. Fourteen patients complained of dribbling ejaculation, and 27 of non-climactic ejaculation (13 no sensation, 10 some sensation, 4 painful sensation). Medical assessments showed absent or diminished anal sensation in 28 patients, absent or diminished anal reflexes in 21, absent or diminished bulbocavernosus reflexes in 20, but 12/13 positive cremasteric reflex. Urodynamics showed 12/20 areflex and 2/20 hyperactive bladders. Most men with lower lumbosacral lesions maintain natural ejaculation, but often complain of PE following injury. The PE is such that a mere sexual thought can trigger the response, or appear spontaneously as daytime ('sticky paints') or nighttime ('sticky sheets') emissions. PE appears to be a direct consequence of the lesion as it is reported from the very first ejaculation post injury, in men who otherwise controlled their ejaculation prior to injury. Underlying mechanisms may involve sacral inhibition on ejaculation, or simultaneous activation of psychogenic erection and emission. Clinical implications are discussed.

Relationship of toe position sense, neurological level, lesion severity and bulbocavernosus reflex with bladder function in patients with spinal cord injury

Relationship of toe position sense, neurological level, lesion severity and bulbocavernosus reflex with bladder function in patients with spinal cord injury

Intraoperative recording of the bulbocavernosus reflex.

: The bulbocavernosus reflex (BCR) is mediated by the sacral somatic afferent/efferent periphery as well as the sacral cord. Unfortunately, the reflex has suffered from a partly deserved reputation as difficult to implement. However, recent stratagems have improved the test's reliability. Multipulse stimulation (enhanced by double trains as required) and exacting recording technique can yield positive and remarkably reproducible results in patients of all ages and either sex. In this review, we document a 94% baseline BCR acquisition rate among 100 consecutive cases in one institution. Acceptance and routine use of the BCR is needed to help assure optimal post-operative low sacral function in intradural and extradural surgeries at the level of conus medullaris, cauda equina, sacral plexus, and the pudendal nerve. Case studies within this review illustrate the power of the BCR to predict patient outcome or, much more importantly, reverse incipient patient injury in real time.

Place of perineal electrophysiologic testing in multiple sclerosis patients

At present, apart from visual evoked potential testing, clinical neurophysiological testing is rarely used in multiple sclerosis (MS) patients at all. In MS patients with lower urinary tract, bowel and/or sexual dysfunction, which are highly prevalent in MS, clinical neurophysiological tests of the sacral nervous system have been introduced in the past and reported as abnormal. Their usefulness is – in selected patients – to substantiate the suspicion of the neurogenic nature of the pelvic organ dysfunction, but there is no specific recommendation for MS patients. Concentric needle EMG of the perineal muscles, bulbocavernosus reflex latency measurement and pudendal SEP may be particularly useful in those rare patients in whom MS may affect the conus medullaris, to demonstrate “directly” this lesion of the lower sacral segments. Clinical neurophysiological testing retains the potential to further clarify interesting research questions of correlation of nervous system function and pelvic organ dysfunction, particularly relevant for application of sophisticated new rehabilitative methods including electrical stimulation of the nervous system.

P495: Selective loss of the D-wave evoked by contralateral hemispheric transcranial electric stimulation (TES)

Methods: Description of a case series. Eight NF1 patients underwent interventions in order to remove spinal roots neurofibromas causing cervical spinal cord compression. A second intervention at the lumbosacral spine was necessary to remove neurofibromas located at the cauda equina in 2 cases. In all cases, IONM by means of motor evoked potentials (MEPs), somatosensory evoked potentials (SSEPs, epidural SSEPs), D-Wave monitoring and Bulbocavernosus Reflex (BCR) was performed. Additionally, in order to identify motor nerve roots and to preserve their function during surgery, neural tissues mapping was performed by direct electrical stimulation of the structures with a bipolar probe. Results: A total of 54 neurofibromas at the cervical and lumbosacral spine were removed. Motor nerve roots were identified and subtotally resected, sparing rootlets with small tumour nodules. Tumours on sensitive nerve roots were fully resected. When tumours were located at the cauda equina, nerve roots were also monitored using a train of stimulus to determine if these sensitive roots were critically involved in BCR. BCR was successfully elicited in both patients with tumours involving cauda equina and were preserved after tumour removing. No significant changes occurred in MEPs, SSEPs or D-Wave monitoring during surgeries. Conclusions: IONM provides continuous, real-time information about the function of neural pathways at risk during surgery and helps the surgeon to identify motor neural structures. The importance of BCR for the clinical outcome of the patients requires the use of special techniques intended to intraoperatively maintain the reflex. As opposed to schwannomas, neurofibromas grow encasing neural fibres from motor and sensory nerve roots. Subtotal resection should be performed in motor roots in order to preserve motor function.

S40: Intraoperative neurophysiological monitoring in pediatric neurosurgery: a focus on the sacral system

s of Speakers / Clinical Neurophysiology 125, Supplement 1 (2014) S1–S339 S9 anodal direct cortical stimulation, activates the corticospinal tract close to the axon hillock at the border between the grey and the white matter. DCS remains the most focal stimulation possible and thus is favorable used for tumor removal within the vicinity of the motor cortex. MEPs became focus of neurooncological strategies for optimized glioma resection. Combining DCS-MEPs and monopolar cortical/subcortical stimulation mapping techniques in supratentorial tumor surgery as well as combination with intraoperative imaging could achieve supramarginal resection. The proposed subcortical stimulation motor threshold of 2 mA for safe resection has to be confirmed with regard to tumor type and precise location of stimulation. As been shown in cerebral aneurysm surgery, the ability to detect pure motor hemiparesis in carotid endarterectomy was more recently shown in a multicenter study. In spine surgery, presence or disappearance (“all-or-nothing” principle) of MEP amplitude criteria is commonly accepted: the presence of any MEPs is related to unaffected motor function or transient paresis, with the exception of radiculopathy. In cervical and thoracic intramedullary spinal cord surgery, the additional implementation of the D-wave helps to distinguish between permanent and transient motor deficit: D-wave preservation is always followed by a recovery of motor function. The latter seems to be applicable in supratentorial surgeries alike. In summary, MEPs are specific and sensitive for the assessment of the motor cortex and the corticospinal tract. In supratentorial tumor surgery MEPs are increasingly becoming a tool for “functional” guided resection strategies. S40 Intraoperative neurophysiological monitoring in pediatric neurosurgery: a focus on the sacral system F. Sala1, G. Squintani2, V. Tramontano2, C. Arcaro1 1Institute of Neurosurgery, Verona, Italy; 2Division of Neurology, Neurosciences, Verona, Italy Introduction: Intraoperative neurophysiologic monitoring (IOM) is nowadays extensively used in Pediatric Neurosurgery and tethered cord surgery is one of the most useful application. Our goal is to describe and discuss the standard IOM techniques used during tethered cord surgery, in the light of our clinical experience over the past ten years. Material and methods: Neurophysiological mapping of the conus-cauda is performed through direct stimulation of these structures and bilateral recording from segmental target muscles. While mapping identify ambiguous neural structures, their functional integrity during surgery can be assessed by monitoring techniques only, such as somatosensory evoked potentials (SEPs), transcranial motor evoked potentials (MEPs) from limb muscles and anal sphincters, and the bulbocavernosus reflex (BCR). Results: Between 2002 and 2012, we performed 48 surgical procedures in 47 patients with a tethered cord secondary to a variety of spinal dysraphisms. The monitorability rate was 84% for SEPs, 97% for limb muscle MEPs, 74% for the anal sphincter MEPs, and 59% for the BCR. In all patients but one SEP, MEP and BCR remained stable during surgery. Post-operatively two out of 47 patients presented a significant – though transient – neurological worsening. In six patients an unexpected muscle response was evoked by stimulating tissue macroscopically considered as not functional. Conclusions: Mapping techniques allow to identify and spare functional neural tissue and, vice-versa, to cut non-functional structures that may contribute to cord tethering. Monitoring techniques, MEP and BCR in particular, improve the reliability of intraoperative neurophysiology. IOM minimizes neurological morbidity in tethered cord surgery. S41 Neurophysiology of congenital mirror movements

Restoring penis sensation in patients with low spinal cord lesions: The role of the remaining function of the dorsal nerve in a unilateral or bilateral TOMAX procedure

The recently developed TOMAX-procedure restores unilateral genital sensation, improving sexual health in men with a low spinal lesion (LSL). It connects one dorsal nerve of the penis (DNP) to the intact ipsilateral ilioinguinal nerve. We proposed bilateral neurotization for full sensation of the glans but this entails cutting both DNPs, risking patients' erection/ejaculation ability. The objective was to select patients for a bilateral TOMAX-procedure by measuring remaining DNP function, and perform the first bilateral cases. In 30 LSL patients with no penile- but normal groin sensation selected for a unilateral TOMAX-procedure the integrity of the sacral-reflex-arc and DNP function was tested pre-operatively using bilateral needle electromyography (EMG)-bulbocavernosus reflex (BCR) measurements, and an interview about reflex erections (RE) ability. In 13 spina bifida- and 17 spinal cord injury patients [median age 29.5 years (range 13-59 years), spinal lesion T12 (incomplete) to sacral], seven (23%) patients reported RE, four (57%) with intact BCR, and of nine (30%) patients with intact BCR, four reported RE (44%). Even patients with a LSL and no penile sensation can have signs of remaining DNP function, but cutting both DNPs to restore full glans sensation in a bilateral TOMAX-procedure might interfere with their RE/ejaculation. To avoid this risk, we propose a selecting-protocol for a unilateral- or bilateral procedure using RE and BCR measurements. Using this protocol, three patients were bilaterally operated with promising preliminary results. Full sensation of the glans could lead to further improvement in sexual function.

Neuromodulation by surface electrical stimulation of peripheral nerves for reduction of detrusor overactivity in patients with spinal cord injury: A pilot study

ObjectivesTo demonstrate reduction in detrusor overactivity using surface electrical stimulation of posterior tibial nerve (PTN) or dorsal penile nerve (DPN) in patients with spinal cord injury (SCI).DesignPatients with SCI with symptoms of urinary urgency/leaks, with cystometrogram (CMG) proven detrusor overactivity were recruited in this study. Ten persons with observable F-wave from tibial nerve were included in the PTN group. Five persons who had F-wave absent but preserved bulbocavernosus reflex were included in the DPN group. Stimulation was given at 20 Hz, 10–40 mA for 20 minutes/session/day for 14 consecutive days. Detrusor overactivity was recorded using CMG on days 1 and 15.SettingsRehabilitation Institute, Department of Physical Medicine and Rehabilitation, Christian Medical College and Hospital, Vellore, TN, India.ParticipantsPatients with SCI.InterventionsSurface stimulation of peripheral nerves for reduction of detrusor overactivity.Outcome measuresQualitative analysis using voiding diary data and quantitative analysis using CMG data comparing pre- and post-intervention.ResultsP value obtained from voiding chart was 0.021 for PTN and 0.062 for DPN. P value obtained from CMG data was not significant in both groups. In one subject, treatment was extended to 4 weeks and further improvement in voiding diary was seen.ConclusionsIn this pilot study of 15 patients, voiding chart data showed statistically significant improvement following PTN stimulation and trend of improvement following DPN stimulation. However, the CMG data were not statistically significant in this sample population. Further studies with larger, appropriately powered sample size would be helpful to demonstrate the associations of symptoms with CMG data.Trial registrationCTRI no.; CTRI/2012/12/003234; CMCH Approval no.: CMC/IRB/6735/2008/12/18.

Cauda equina and conus medullaris avulsion with herniation after midlumbar chance fracture

A 19-year-old woman arrived to our Level 1 trauma center 2 days after a motor vehicle rollover on the US-Mexico border. The patient's examination revealed absent sensation to light touch and pinprick below T11, 0/5 motor function in bilateral lower extremities (including 0/5 function in bilateral iliopsoas), absent rectal tone, and no appreciable bulbocavernosus reflex. Initial computed tomography revealed an L3 vertebral fracture extending from the anteroinferior end plate through the middle column and posterior vertebral cortex.

Electrophysiological study of the bulbocavernosus reflex: normative data.

In the clinical setting the bulbocavernosus reflex (BCR) is elicited by squeezing the glans penis and digitally palpating the contraction of the bulbocavernosus (BC) muscle. In neurophysiology the BCR is obtained by stimulating the dorsal nerve of the penis or clitoris and by recording the response from BC muscle and it should be performed in selected patients with suspected urinary, bowel, or sexual neurogenic dysfunction. The BCR is considered one of the sacral neurophysiological tests of the greatest clinical utility. Previous normative data were obtained on small samples. The aim of this study was to determine normative values for the BCR in a large sample of men. We studied a large population (105 men; mean age 53 years, range 19-73 years) without central or peripheral neurological diseases. In each subject the sacral reflex was elicited by electrical stimulation of the base of the dorsum penis and recorded using a surface electrode from the BC muscle. We recorded the latency, calculated at onset, and the maximal amplitude of response, calculated peak to peak. We were able to detect the BCR in all the men. No correlation between BCR latency and age was found (r=0.136; p=0.160). The mean onset latency value was 33.0±4.85 ms (mean±2SD, range 26.8-39.4). The mean amplitude value was 16.53±12.21 μV (mean±2SD, range 4.2-43.6). Our normative data on the BCR were similar to previously published data.

Intraoperative neurophysiology in tethered cord surgery: techniques and results

Intraoperative neurophysiologic monitoring (IOM) is nowadays extensively used to minimize neurological morbidity in tethered cord surgery. Our goal is to describe and discuss the standard IOM techniques used during these surgical procedures and to summarize our clinical experience using a multimodal IOM approach. Neurophysiological mapping of the conus-cauda is performed through direct stimulation of these structures and bilateral recording from segmental target muscles. While mapping identifies ambiguous neural structures, their functional integrity during surgery can be assessed by monitoring techniques only, such as somatosensory evoked potentials (SEPs), transcranial motor-evoked potentials (MEPs) from the limb muscles and anal sphincters, and the bulbocavernosus reflex (BCR). Between 2002 and 2012, we performed 48 surgical procedures in 47 patients with a tethered cord secondary to a variety of spinal dysraphisms. The monitorability rate was 84 % for SEPs, 97 % for limb muscle MEPs, 74 % for the anal sphincter MEPs, and 59 % for the BCR. In all patients but one, SEP, MEP, and BCR remained stable during surgery. Postoperatively, two out of 47 patients presented a significant-though transient-neurological worsening. In six patients, an unexpected muscle response was evoked by stimulating tissue macroscopically considered as not functional. Mapping techniques allow identifying and sparing functional neural tissue and vice versa to cut nonfunctional structures that may contribute to cord tethering. Monitoring techniques, MEP and BCR in particular, improve the reliability of intraoperative neurophysiology, though these may require a higher degree of neuromonitoring expertise. IOM minimizes neurological morbidity in tethered cord surgery.

Standard Operating Procedures for Neurophysiologic Assessment of Male Sexual Dysfunction

Can neurophysiological testing in male patients with sexual dysfunction benefit the decision-making process? The answer remains unclear. To provide standard operating procedures for the neurophysiologic assessment of male sexual dysfunction. Medical literature was reviewed and combined with expert opinion of the authors. Bulbocavernosus reflex latency time, pudendal somatosensory evoked potentials, and sympathetic skin responses have been considered as potential candidates for the diagnosis and assessment of erectile dysfunction (ED). Currently, there is no consensus on a standardized methodology for these neurophysiological investigations in the overall assessment of ED. These procedures are unable to assess the integrity of the efferent parasympathetic proerectile penile innervation; accordingly, none of these assessment procedures is recommended for ED patients. Corpus cavernosum electromyography (CC-EMG) can detect abnormalities in cavernous smooth muscle although these alterations can be attributed both to damage to autonomic penile innervation and to degenerative processes of the cavernous smooth muscle. CC-EMG is still considered experimental. Evidence does not support that men with premature ejaculation (PE) are consistently characterized by penile hypersensitivity; accordingly, penile threshold determination is not recommended to in the diagnosis of PE. Neurophysiological investigation of other components of the penile sensory pathways in PE patients has not provided any definitive contribution to the diagnosis. No neurophysiological assessment procedures yield additional information that consistently aids in the assessment of PE and ED.

Use of the bulbocavernosus reflex system in assessing voiding dysfunction

The Bulbocavernosus Reflex System (BRS) (Laborie, Canada) is an office-based procedure used to measure the bulbocavernosus reflex (BCR) latency period. The aim of this study is to evaluate the BCR as a predictor of specific voiding dysfunction patterns confirmed by urodynamics (UDS). A total of 87 men were evaluated with BRS, UDS, and electromyography at Weill Cornell Medical College from March to August 2010. Baseline characteristics, demographics, UDS, and latency parameters were recorded. Multivariate logistic regression analysis was performed to evaluate prolonged BCR (latency >45 ms) as a predictor of specific voiding dysfunction patterns. The median age of men was 70.4 years (IQR 57.6-75.6). Based on UDS, 60 men were given a primary or secondary diagnosis of bladder outlet obstruction (BOO), 43 a diagnosis of detrusor overactivity (DO), 11 a diagnosis of intrinsic sphincter deficiency (ISD), and 4 a diagnosis of detrusor sphincter dyssynergia (DSD). Median BCR latency was 57.0 ms (IQR 47.5-76.5) and 68 (78%) men demonstrated a prolonged latency. In multivariate analysis, latency period was not significantly associated with DO, BOO, ISD, or DSD (p = 0.067, 0.696, 0.999, 0.971, respectively). Prolonged bulbocavernosus reflex latency was not associated with DO, BOO, ISD, or DSD. Although evidence in the literature suggests a link between this reflex arc and voiding, its specific diagnostic role remains unclear. Large prospective trials are needed to further explore the role of BCR in the evaluation of patients with voiding dysfunction.

Large caliber ballistic fragment within the spinal canal

Gunshot wounds to the spine continue to be a prodigious clinical problem. We report a case of a 28-year-old male US Marine after a high-energy penetrating spinal cord injury, with associated injuries including a left hemopneumothorax and an open left comminuted scapula body fracture. Computed tomography demonstrated a retained highcaliber (7.62 mm) ballistic fragment within the spinal canal at the level of T6–T7 (Figs. 1 and 2). On physical examination, the patient had an incomplete spinal cord injury (American Spinal Injury Association Grade B) with sacral sparing demonstrating normal rectal tone, voluntary rectal squeeze, and bulbocavernosus reflex. The patient had 0/5 motor strength in bilateral lower extremities, normal sensation T6 right/T5 left, intact proprioception in bilateral ankles and toes, and normal strength/sensation in bilateral upper extremities. On Postinjury Day 5, the patient underwent a T6 laminectomy, removal of the bullet, and subsequent repair of a dural defect. This is the first case of a large caliber bullet being lodged in the spinal canal, with only a few reported case series of combat casualties treated for high-velocity ballistic injuries to the spinal column [1,2]. When treating gunshot wounds to the spine, it is of the utmost importance to differentiate between high- and low-energy ballistic injuries as this dictates the appropriate management [3]. Highenergy ballistic injuries are more common in combat casualties compared with civilian trauma patients and are often associated with significantly greater soft-tissue devitalization and a larger zone of injury. Treatment of high-energy ballistic injuries should consist of early broad-spectrum intravenous antibiotics, aggressive surgical debridement, and, when indicated, decompressive laminectomy with instrumentation at a Level 4 or 5 treatment facility. Fractures of the spine caused by low-velocity bullet wound or ballistic fragmentation are usually stable, and surgical intervention is often unnecessary. Most cases of spine instability and late deformity after penetrating injury have been associated with overly aggressive laminectomy [3,4].

REPLY

Study Type – Aetiology (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is known that foreskin, but not glans penis, contains a high density of fine-touch mechanoreceptors. Clinically the penilo-cavernosus reflex provides information on function of the sacral nerves. The study demonstrated that in the majority of circumicised men this reflex cannot be elicited clinically, but can be measured neurophysiologically. OBJECTIVE • To test clinical observations that the penilo-cavernosus reflex is much more difficult to elicit in circumcised men. PATIENTS AND METHODS • Men consecutively referred for uro-neurological or uro-neurophysiological examination were prospectively included. • Those with possible sacral neuropathic lesions were excluded. • A history was obtained, and a clinical neurological examination was performed. • The penilo-cavernosus reflex was tested clinically and neurophysiologically using electrical and mechanical stimulation. • Reflex elicitability scores in groups of circumcised men, men with foreskin retraction and a control group of uncircumcised men were compared using the Mann–Whitney U test. RESULTS • The reflex was clinically non-elicitable in 73%, 64% and 8% of 30 circumcised men, 15 men with foreskin retraction, and 29 control men, respectively. • The scored reflex elicitability was significantly (P < 0.001) higher in control men than in the other two groups clinically, but not neurophysiologically. CONCLUSION • The study confirmed the lower clinical and similar neurophysiological elicitability of the penilo-cavernosus reflex in circumcised men and in men with foreskin retraction. This finding needs to be taken into account by urologists and other clinicians in daily clinical practice.

Proctalgies fugaces et neuropathie pudendale : étude neurophysiologique périnéale chez 55 patients

Proctalgia fugax (PF) is a very common condition especially in women. Causes and pathophysiological mechanisms of PF are unknown. Recently, a pudendal neuropathy was clinically suspected in women with PF. The goal of our study was to demonstrate, or not, such abnormalities by means electrophysiological testing. Fifty-five patients with PF (45 female and 10 male, mean age 50.2 years) were evaluated. EMG testing with motor unit potential analysis of pelvic floor muscles (bulbocavernosus muscle and striated external anal sphincter), study of bulbocavernosus reflex and pudendal nerve terminal motor latencies (PNTML) were performed. EMG testing was altered in two males out of 10 (20%) and 29/45 females (64%). In women, denervation was found bilateral in 25/29 (86%). Sacral latency was delayed in eight out of 29 (bilateral in five cases, unilateral in three cases) and PNTML altered in 17 cases (13 bilateral alteration, four unilateral). A significant difference (P<0.002 Chi(2) test) was demonstrated between male and female concerning pelvic floor muscles denervation. Pelvic floor muscles denervation was a common feature in women suffering from PF, due to a stretch bilateral pudendal neuropathy. Distal lesions of the pudendal nerves, principally due to a stretch perineal neuropathy, can be imagined as a factor or co-factor of PF.