Complete Emptying Research Articles

Neuromodulation through sacral nerve roots 2 to 4 with a Finetech-Brindley sacral posterior and anterior root stimulator.

Investigation of five patients receiving an implant, using laboratory cystometry and self-catheterisation at home. To use the established Finetech-Brindley sacral root stimulator to increase bladder capacity by neuromodulation, eliminating the need for posterior rhizotomy, as well as achieving bladder emptying by neurostimulation. Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. Five patients underwent implantation of a Finetech-Brindley stimulator without rhizotomy of the posterior roots. This was either a two channel extradural device (four cases) or a three channel intrathecal device (one case). In each patient, the implant was configured as a Sacral Posterior and Anterior Root Stimulator (SPARS). Postoperatively, repeated provocations using rapid instillation of 60 ml saline were used to determine the relative thresholds for neuromodulation using each channel. The effect of continuous neuromodulation was examined in the laboratory using slow fill cystometrograms, and conditional stimulation was also studied (neuromodulation for 1 min to suppress hyperreflexic contractions as they occurred). In one patient, neuromodulation was applied continuously at home, and volumes at self catheterisation recorded in a diary. Reflex erections were preserved in each patient. In three patients, detrusor hyperreflexia persisted postoperatively and neuromodulation via the implant was studied. In these three patients, the configuration was: S2 mixed roots bilaterally (channel B), and S34 bilaterally (channel A). Both channels could be used to suppress provoked hyperreflexic contractions, with the S2 channel effective at a shorter pulse width than S34 in a majority of cases. Continuous stimulation more than doubled bladder capacity in two out of three patients during slow fill cystometry. Conditional stimulation was highly effective. In the one patient who used continuous stimulation at home, bladder capacity was more than doubled and the effect was comparable with anticholinergic medication. Bladder pressures >70 cm water could be achieved with intense stimulation in three patients, but detrusor-external urethral sphincter dyssynergia (DSD) prevented complete emptying. Neuromodulation via a SPARS was effective and may replace the need for posterior rhizotomy. However, persisting DSD may prevent complete bladder emptying and warrants further investigation.

Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment.

Symptom relief post pneumatic dilation is traditionally used to assess treatment success in achalasia patients. Recently, we showed that symptom relief and objective oesophageal emptying are concordant in about 70% of patients, while up to 30% of achalasia patients report near complete symptom relief despite poor oesophageal emptying of barium. We now report the results of long term clinical follow up in these two groups of achalasia patients, assessing differences in symptomatic remission rates. Achalasia patients undergoing pneumatic dilation since 1995 were evaluated both symptomatically and objectively at regular intervals. Pre and post dilation symptoms were recorded. Barium column height was measured five minutes after ingesting a fixed volume of barium per patient to assess oesophageal emptying. Patients who initially reported near complete symptom relief were divided into two groups based on objective findings on barium study: (1) complete oesophageal emptying (concordant group), and (2) poor oesophageal emptying (discordant group). Patients were followed prospectively for symptom recurrence. Thirty four patients with complete symptom relief post pneumatic dilation were identified. In 22/34 (65%) patients, the degree of symptom and barium height improvements was similar (concordant group). In 10/34 (30%) patients, there was < 50% improvement in barium height (discordant group). Significantly (p<0.001) more discordant (9/10; 90%) than concordant (2/22; 9%) patients failed therapy at the one year follow up. Seventeen of 22 (77%) concordant patients were still in remission while all discordant patients had failed therapy by six years of follow up. Length of time in symptom remission (mean (SEM)) post pneumatic dilation was significantly (p=0.001) less for the discordant group (18.0 (3.6) months) compared with the concordant group (59.0 (4.8) months). (1) Poor oesophageal emptying is present in nearly 30% of achalasia patients reporting complete symptom relief post pneumatic dilation. (2) The majority (90%) of these patients will fail within one year of treatment. (3) Timed barium oesophagram is an important tool in the objective evaluation of achalasia patients post pneumatic dilation.

Mesorectal excision for rectal cancer: functional outcome after low anterior resection and colorectal anastomosis without a reservoir.

OBJECTIVE: The anal sphincters, neorectal capacity and motility may be affected by injury to the autonomic nerves during rectal resection. Anorectal function also depends on the method used for restoration of intestinal continuity, and colonic reservoir reconstruction has been recommended in ultralow anastomosis. This study was undertaken to evaluate the results after nerve preserving mesorectal excision and colorectal anastomosis without a reservoir. PATIENTS AND METHODS: Thirty-five consecutive patients who underwent low anterior resection with primary healing of the anastomosis, were included. Anal manometry with stationary pull through technique, rectal volumetry and symptom scoring (written questionnaires with visual analogue scales) were performed prior to and 12 months after surgery. Anal sphincter function was evaluated in all patients, but five patients with a colonic reservoir were excluded from the other evaluations. Thirty patients entered the main study; 14 patients having a total mesorectal excision (TME) and a low anastomosis (LA) (4-6 cm) and 16 patients a partial mesorectal excision (PME) and a high anastomosis (HA) (7-11 cm from the anal verge). RESULTS: Anal resting and squeeze pressure and rectal sensibility (threshold volume) were unchanged after the operation. The rectal volume eliciting urge to defecate was reduced from median 95 ml to 70 ml (P < 0.01), and the maximum tolerable rectal volume was reduced from 200 to 135 ml (P < 0.01) after the operation. The maximum tolerable volume was significantly lower in patients with LA than in patients with HA (P < 0.01). Overall functional results were good. The patients reported problems with complete bowel emptying (median VAS-score reduction from 90 to 60, P < 0.01), and minor incontinence problems (median VAS-score reduction from 100 to 90, P= 0.03). The reduction of VAS-scores was more pronounced in LA than HA patients (without reaching statistical significance). CONCLUSIONS: Anal sphincter function was preserved after mesorectal excision. Neorectal capacity was reduced, most pronounced in patients with LA. The overall functional results were satisfactory and slightly better in patients with HA than in those with LA.

Assessment and conservative management of the neuropathic bladder.

The etiologies and forms of congenital neuropathic bladder are described: contractile (25%), acontractile (15%), and intermediate (60%). The terminology relating to neuropathic bladder is defined and the principles of bladder management are highlighted: (1) must achieve a bladder that can fill at low pressure, (2) must achieve a bladder that can store urine at low pressure, (3) must achieve sphincter resistance that is sufficient to allow urine storage, and (4) must put in place a mechanism of achieving complete voluntary bladder emptying. The approach to investigation is set out in a logical sequence, and the methods of achieving the goals highlighted above are described. All of this is put in the context of managing the handicapped patient as a whole. It also is stressed that the aim is not just to achieve continence but perhaps even more importantly to protect renal function.

Does post-voiding residual volume get less as mobility improves in a rehabilitation ward for older adults?

Impaired bladder emptying is common in frail older adults. This study tests the hypothesis that more complete bladder emptying is associated with better mobility in a rehabilitation ward for older adults. Consecutive admissions to a rehabilitation ward for older adults were considered for inclusion in the study in the week after admission to the ward. Exclusion criteria were cognitive impairment such that consent could not be obtained, non-English speaking, or presence of an indwelling urinary catheter. A post-voiding residual (PVR) bladder volume and Rivermead Mobility Index (RMI) were completed for subjects who gave consent, on a weekly basis until discharge. The BladderScan BVI 3000, Diagnostic Ultrasound, instrument was used. Statistical analysis was by a general linear mixed model. In the study period, 114 people were admitted and 57 approached for consent. Twenty-four people gave consent. Fifty percent of participants had at least one PVR greater than 100 mL. One person was found to be in urinary retention, with a PVR of greater than 700 mL, and was excluded from further analysis. The PVR increased by 1.2 mL (95% CI-4.6 to 7) for each unit improvement in the RMI. This study suggests that PVR does not decline with improvement in mobility in older adults receiving inpatient rehabilitation.

Dynamic imaging of endoplasmic reticulum Ca2+ concentration in insulin-secreting MIN6 Cells using recombinant targeted cameleons: roles of sarco(endo)plasmic reticulum Ca2+-ATPase (SERCA)-2 and ryanodine receptors.

The endoplasmic reticulum (ER) plays a pivotal role in the regulation of cytosolic Ca(2+) concentrations ([Ca(2+)](cyt)) and hence in insulin secretion from pancreatic beta-cells. However, the molecular mechanisms involved in both the uptake and release of Ca(2+) from the ER are only partially defined in these cells, and the presence and regulation of ER ryanodine receptors are a matter of particular controversy. To monitor Ca(2+) fluxes across the ER membrane in single live MIN6 beta-cells, we have imaged changes in the ER intralumenal free Ca(2+) concentration ([Ca(2+)](ER)) using ER-targeted cameleons. Resting [Ca(2+)](ER) (approximately 250 micromol/l) was markedly reduced after suppression (by approximately 40%) of the sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA)-2b but not the SERCA3 isoform by microinjection of antisense oligonucleotides, implicating SERCA2b as the principle ER Ca(2+)-ATPase in this cell type. Nutrient secretagogues that elevated [Ca(2+)](cyt) also increased [Ca(2+)](ER), an effect most marked at the cell periphery, whereas inositol 1,4,5-trisphosphate-generating agents caused a marked and homogenous lowering of [Ca(2+)](ER). Demonstrating the likely presence of ryanodine receptors (RyRs), caffeine and 4-chloro-3-ethylphenol both caused an almost complete emptying of ER Ca(2+) and marked increases in [Ca(2+)](cyt). Furthermore, photolysis of caged cyclic ADP ribose increased [Ca(2+)](cyt), and this effect was largely abolished by emptying ER/Golgi stores with thapsigargin. Expression of RyR protein in living MIN6, INS-1, and primary mouse beta-cells was also confirmed by the specific binding of cell-permeate BODIPY TR-X ryanodine. RyR channels are likely to play an important part in the regulation of intracellular free Ca(2+) changes in the beta-cell and thus in the regulation of insulin secretion.

‘An empty and happy feeling in the bladder…’: health changes experienced by women after acupuncture for recurrent cystitis

Objective: The aim of this study was to explore changes in health as reported by cystitis-prone females after having received prophylactic acupuncture treatment for recurrent cystitis. Design: A qualitative study based on written free text answers on the women's own experience of changes related to health after completion of TCM acupuncture treatment. Data were analyzed using Giorgi's phenomenological approach. Setting: Subjects living in the Bergen area, Norway, were recruited by advertisement in local newspapers and included provided they had had three or more episodes of lower UTI during the previous 12 months. Results: The main topics reported were related to improved pressure during micturition and more complete bladder emptying; more normal bowel movement and less abdominal discomfort; more energy, reduced stress level, and better sleep. Only a few reported feeling worse. Conclusion: The symptoms described as relieved by the women in our study seem to fit TCM theory for diagnoses of their vulnerability to cystitis. Qualitative methods have a role in TCM research that may enrich our knowledge in other ways than traditional quantitative methods may.

INEFFICIENT URETHRAL MILKING SECONDARY TO URETHRAL DYSFUNCTION AS AN ADDITIONAL RISK FACTOR FOR INCONTINENCE AFTER RADICAL PROSTATECTOMY

Continence after radical prostatectomy is thought to depend completely on the striated urethral sphincter. However, some patients complain only of occasional post-void dribbling. Therefore, we determined whether urethral dysfunction may be another cause of incontinence. The sensory threshold of electric stimulation was measured by double ring electrodes in the membranous urethra and 2.5 cm. distal in 29 men before and in 29 after radical retropubic prostatectomy. In addition, voiding cystourethrography was performed in 66 patients before and in 49 after surgery to determine complete post-void urethral emptying or milking. The mean sensory threshold of the membranous urethra was 15 +/- 3 mA. preoperatively versus 38 +/- 17 postoperatively (p <0.0001). The sensory threshold 2.5 cm. further distal was 12 +/- 5 mA. before and 10 +/- 4 after radical prostatectomy, which was not statistically significant. Postoperatively in completely continent patients and in those with dribbling the mean threshold was 32 +/- 12 and 43 +/- 18 mA. in the membranous urethra (p = 0.09), and 11 +/- 4 and 9 +/- 4 mA. in the bulbar urethra, respectively, which was not statistically significant. Of the 66 patients 36 (55%) showed post-void urethral milking before surgery but only 8 of 49 (16%) showed it postoperatively (chi-square test p <0.0001), including 7 who were completely continent and 1 who complained of occasional post-void dribbling. After radical prostatectomy sensitivity of the membranous but not of the bulbar urethra is affected, correlating with postoperative continence. In addition, post-void dribbling seems to be associated with the loss of urethral milking. We conclude that preserving urethral function is another important continence factor after radical prostatectomy.

Orthotopic Urinary Diversion Using an Ileal Low-Pressure Bladder Substitute with an Afferent Tubular Segment

The use of ileum for orthotopic bladder substitution has gained general acceptance, and different surgical techniques have been described. Independent of the surgical technique, preoperative evaluation is one important factor determining successful outcome. More restrictive indications for an ileal bladder substitute, simpler surgical techniques, and good quality postoperative care and rehabilitation (eg, micturition technique, complete bladder emptying), accompanied by regular, lifelong follow-up by an experienced specialist, will produce the best results. The surgical technique described here offers several significant advantages, and is not more complex than an ileal conduit. The aboral end of the isolated ileal segment, which is 2 to 2.5 times longer than for an ileal conduit, is formed into a low-pressure, high-capacity reservoir according to the Goodwin Cup-patch-technique and readapted to the membranous urethra. The pouch constructed from 40 cm to 44 cm of ileum according to this technique has an optimal surface/volume ratio, with limited reabsorptive bowel surface and adequate surface tension to allow a sensation of bladder fullness and complete bladder emptying. At the same time, placement of an afferent isoperistaltic tubular ileal segment allows resection of the distal ureters, the periureteral lymphatics, and the bladder en bloc. This lessens the risk of local recurrence in the distal ureters, and the high dissection of the ureters minimizes the risk of ischemia and the resulting tendency for strictures and stenosis. The isoperistaltic afferent tubular segment functions as an adequate dynamic antireflux mechanism in this low-pressure system and allows simple end-to-side anastomosis of the ureters with a low complication rate. In the rare cases of local recurrence in the pelvis or in the urethra necessitating a urethrectomy, the afferent tubular segment can easily be converted into an ileal conduit. Furthermore, resection of the relatively short ileal segment of 54 cm to 56 cm, and leaving the terminal 25 cm of the ileum and the ileocecal valve intact, help to minimize malabsorption.

Physical therapy management of pelvi/perineal and perianal pain syndromes.

Pelvic floor physical therapy is considered to be effective in the management of functional urogenital and anorectal disorders. A functioning pelvic floor is integral to increases in intra-abdominal pressure, provides rectal support during defecation, has an inhibitory effect on bladder activity, helps support pelvic organs, and assists in lumbopelvic stability. Coordinated release of the sphincters within a supporting extensible levator ani allows complete and effortless emptying. A major feature of pelvi/perineal and perianal pain syndromes commonly encountered by multidisciplinary clinicians is pelvic floor imbalance and incoordination. Precise pelvic floor and abdominal muscle coactivity, based on research, is used clinically. Motor and cognitive learning which can alter peripheral and central pain mechanisms and produce physical changes in the CNS, viscera, smooth and musculoskeletal tissues is the basis of physical therapy in pelvic floor and pelvic organ pain management.

The Ca2+ concentration of the endoplasmic reticulum is a key determinant of ceramide-induced apoptosis: significance for the molecular mechanism of Bcl-2 action.

The mechanism of action of the anti-apoptotic oncogene Bcl-2 is still largely obscure. We have recently shown that the overexpression of Bcl-2 in HeLa cells reduces the Ca2+ concentration in the endoplasmic reticulum ([Ca2+]er) by increasing the passive Ca2+ leak from the organelle. To investigate whether this Ca2+ depletion is part of the mechanism of action of Bcl-2, we mimicked the Bcl-2 effect on [Ca2+]er by different pharmacological and molecular approaches. All conditions that lowered [Ca2+]er protected HeLa cells from ceramide, a Bcl-2-sensitive apoptotic stimulus, while treatments that increased [Ca2+]er had the opposite effect. Surprisingly, ceramide itself caused the release of Ca2+ from the endoplasmic reticulum and thus [Ca2+] increased both in the cytosol and in the mitochondrial matrix, paralleled by marked alterations in mitochondria morphology. The reduction of [Ca2+]er levels, as well as the buffering of cytoplasmic [Ca2+] changes, prevented mitochondrial damage and protected cells from apoptosis. It is therefore concluded that the Bcl-2-dependent reduction of [Ca2+]er is an important component of the anti-apoptotic program controlled by this oncogene.

Pneumocystography in nonpalpable breast cysts: effect on remission rate

The purpose of the study was to evaluate the effect on remission rate after pneumocystography among nonpalpable cysts. A series of 206 nonpalpable cysts aspirated using the perforated compression plate technique was reviewed. The effect on remission was evaluated on mammograms obtained 1-3 years after the cyst aspiration. Logistic regression was used to compare the effect between those examined with pneumocystography (n=62) and those aspirated alone (n=144). The ratio of complete remission was 52% (32/62) with pneumocystography compared to 53% (76/144) without. In univariate analysis there was no association between pneumocystography and complete remission. However, complete emptying of the cyst was significantly associated with complete remission (OR = 1.85, 95%CI = 1.05-3.25). In a multivariate model, complete emptying without pneumocystography was significantly associated with complete remission (OR = 2.40, 95%CI = 1.14-5.02) but not complete emptying in combination with pneumocystography (OR = 0.84, 95%CI = 0.24-2.89). Pneumocystography showed a close to two-fold association with complete remission. However, this association was not statistically significant (OR = 1.92, 95%CI = 0.52-7.05). In conclusion, complete emptying of a nonpalpable cyst significantly increased the chance of complete remission when pneumocystography was not performed. Pneumocystography showed no significant effect on remission rate.

Device-induced ventricular geometric remodeling: appraisal of critical issues.

Devices to therapeutically alter the shape of failing left ventricles are being developed by at least two laboratories. This review attempts to assess potential for benefit and possible negative consequences of the device concepts. Data from all known publications and scientific presentations were reviewed. Findings address four key issues: (1) Predictions, based on physical computations, of direct beneficial reduction in myocardial afterload are indeed computationally realistic and supported by effects reported experimentally. (2) Concerns that remodeling might necessitate unacceptably high epicardial contact pressure appear unfounded. Computational force modeling indicates that with optimization of contact area and contour, the expected degree of remodeling (approximately 20% effective radius reduction) might be achieved by epicardial pressures very near existing endocardial pressures, and in diastole, well below arterial perfusion pressures. Reported augmentation of systolic function suggests that there is no significant compromise of regional perfusion in acute (< or = 4 weeks) preclinical studies. (3) If intramural tangential shear stresses were sustained by local bending, detrimental tensile/compressive stresses might be introduced. However, microstructure predicts and reported evidence confirms rapid shear-stress relaxation. (4) The same reduction in wall-stress/chamber-pressure ratios that produces benefit during systole would simultaneously worsen diastolic same-volume stiffness. However, if better systolic contraction effects more complete emptying, operational volume range should become incrementally lower, at least compensating. This is supported by early published data. There appears to be solid computational and early experimental support for the concept of geometric ventricular remodeling. If one or more of the devices being tested should prove to be safe and effective, left ventricular geometric remodeling will be of substantial benefit in heart failure treatment.

Bladder response to urethral flow in the awake ewe.

The flowing of fluid along the urethra can facilitate the bladder micturition contraction, a reflex appropriate to achieve complete bladder emptying. The response has been observed in animals studied in the decerebrate, spinal, or anesthetized intact state but is difficult to demonstrate in awake, healthy humans. The aim of this study was to investigate this reflex in the awake, intact state using urodynamics in the ewe. The animals were fully awake and lay gently restrained on a recording table. The bladder was catheterized, and urethral flows were obtained by slowly injecting saline at the level of the proximal urethra. Bladder and rectal pressure were monitored, and the responses to urethral flow were tested at various bladder volumes. Urethral flows consistently evoked detrusor contractions in all animals. The response started approximately 2 seconds after the beginning of the flow and largely outlasted the stimulus. Its amplitude was similar to that of the bladder-to-bladder micturition reflex, and, like the latter, it always required some degree of bladder filling to appear. The reflex was selectively suppressed by local anesthesia of the urethral mucosa, indicating that the effect must originate from urethral receptors. Small urethral flows thus appear to elicit large bladder micturition contractions in awake healthy animals, and the reflex could be quite significant during the normal micturition. That this reflex is found in all studied species further supports the notion that the negative results in normal awake humans are owing to descending inhibitory controls rather than to the lack of appropriate pathways.

Urinary tract infection in children: a review of its pathogenesis and risk factors.

Urinary tract infection (UTI) is one of the commonest bacterial infections seen in children, ranking second only to those of the respiratory tract. A steady flow of urine, complete emptying of the bladder and various host defences provide the principal means of protection. Urinary stasis, on the other hand, provides an opportunistic environment for bacterial multiplication; several other factors also contribute to UTI, such as urinary obstruction, vesico-ureteric reflux (VUR) and other urinary tract malformations. UTI, especially in the presence of VUR, may lead to scarring of the kidney and progressive renal disease. It is vital, therefore, to diagnose such anomalies at an early stage, the overall aim being to identify those at high risk so that measures may be taken to prevent serious complications and preserve renal function. Those at low risk of UTI, however, should not be over investigated; this is in order to keep invasive procedures down to a minimum. Whenever possible, the management of high risk cases is best discussed between paediatrician, microbiologist, radiologist, urologist and the general practitioner.

Constipation

OBJECTIVE: To review current information concerning the importance, pathophysiology, clinical presentation, and treatment of chronic constipation in Pediatrics. METHODS: Bibliographic review of Medline database and articles published by the authors. RESULTS: Constipation is a common disorder in childhood. The pathophysiology of constipation involves the interaction of several factors: low-fiber diet, early weaning, painful bowel movement, fecal retention, disturbance of intestinal motility, and genetic predisposition. The clinical presentation of children with constipation is variable. Several patients present the onset of constipation during the 1st year of life; however, the medical treatment is usually initiated only after a long period. Some patients are recognized due to the presence of complications, such as soiling, abdominal pain, and urinary abnormalities. The treatment should be adapted to each patient, and includes general orientation, complete colonic emptying, maintenance treatment, and a behavioral program to regulate bowel habits. Regardless of the fact that most children present functional chronic constipation, much attention should given to the entities that constitute the differential diagnosis. Specialized evaluation and diagnostic techniques should be indicated according to the patient s individual characteristics and when the clinical evolution is not satisfactory. CONCLUSIONS: The long-term control of chronic constipation depends on the acquisition of dietary habits that provide an adequate intake of dietary fiber. It is possible that a high-fiber diet is important not only to the control of constipation, but may also reduce the risk for diet-related chronic diseases during adulthood.

Unusual presentation of lichen sclerosuis in an adolescent

Background: The presentation of lichen sclerosus has been described in detail in the adult literature. Typically present with symptoms of itching and soreness in the vulvar area at which time a vulvar evaluation reveals a specific appearance. The presentation is believed to be similar in prepubertal children and adolescents. In this case report we encountered an unusual initial presentation of this disease.Methods: Case presentation.Results: An 18-year-old female presented for the first time to her gynecologist with complaint of difficulty with complete emptying of bladder and dribbling. She had noted the onset of these symptoms two months prior to presentation. She denied any long-term history of vulvar itching or irritation. Her menses were normal with no complaints of dysmenorrhea. Onset of menarche and pubertal development were also normal. She denied any pre-pubertal history of labial adhesions or lichen sclerosis. The patient was not sexually active. She was diagnosed with labial adhesions and her first course of treatment included topical estrogen therapy for 8 weeks. Her second course of therapy included topical testosterone for 6 weeks without any improvement or side effects. On evaluation at our institution the posterior aspect of the labia minora could not be seen and the area of the vaginal introitus was completely obstructed (see picture). The clitoral hood could not be retracted and the surrounding vulva appeared atrophic and white. The degree of obstruction was such that the urethra could not be seen. In the operating room the labia minora were manually separated. The patient applied clobetasol .05% ointment for the next two weeks to the vulva and then switched to a less potent steroid. Follow-up evaluation 2 and 4 weeks after the procedure did not show any adhesions. Punch biopsy was consistent with diagnosis of lichen sclerosis.Conclusion: The presentation of lichen sclerosis may be variable in adolescents; thus, a high index of suspicion must be maintained to make this diagnosis.

Ultrasound technique for measuring mammary cistern size of dairy ewes.

Sarda ewes, ∼4·5 million animals producing 500 000 tonnes milk annually, are one of the most important breeds of dairy sheep in the Mediterranean area. Several studies (Casu &amp; Labussière, 1972; Labussière et al. 1981; Gallego et al. 1983; Rebello de Andrade et al. 1989; Bencini, 1993) have shown that milk production is influenced by mammary gland size and cistern dimension. The size of the mammary cistern affects both milk secretion rate and milk emission kinetics during milking.Milk secretion rate is controlled at the mammary gland level mainly by a protein feedback inhibitor of lactation (FIL), which is produced by mammary epithelial cells and secreted together with milk into the alveoli (Wilde &amp; Peaker, 1990). As the alveoli are the site of action of the FIL (Henderson &amp; Peaker, 1984), the FIL affects the rate of secretion when the milk is stored in the secretory tissue, whereas it is inactive in the milk stored in the cistern. As a consequence, the action of the FIL should be less in animals with a greater cistern volume, because a large proportion of milk is stored in the mammary cistern and the time during which the milk is in contact with the alveoli is reduced. This hypothesis is supported by the finding that the milk production of cows (Dewhurst &amp; Knight, 1992; Knight &amp; Dewhurst, 1992, 1994) and sheep (Karam et al. 1971; Enne et al. 1972) with large cistern storage capacities was almost unaffected by changes in the frequency of milking.Cistern volume also affects milk emission kinetics and the proportion of stripped milk obtained at milking (Labussière, 1988). Cisternal milk is immediately available for removal, whereas alveolar milk is available only after operation of the ejection reflex, necessary in dairy ewes for complete udder emptying (Bruckmaier et al. 1997). Therefore, in animals readily able to expel alveolar milk into the cistern before the whole cisternal milk fraction is removed (Pazzona et al. 1978; Bruckmaier et al. 1997), a larger cistern volume enables milking time to be reduced by eliminating or restricting the need for stripping.On the basis of the above considerations, the volume of the mammary gland cistern could be proposed as a selection objective to improve milk production and milking ability of dairy ewes. For this purpose, a quick, accurate and economic method for measuring it is needed. The ultrasound technique allows the internal structure of the mammary gland cistern to be observed clearly in sheep (Ruberte et al. 1994; Pulina et al. 1996; Bruckmaier et al. 1997), cows (Bruckmaier et al. 1994b) and goats (Bruckmaier et al. 1994a). Cistern size has been measured by ultrasound in dairy cows (Bruckmaier et al. 1994b) and sheep (Pulina &amp; Nudda, 1996), where a positive correlation between milk yield and cistern area calculated from the ultrasound images of mammary glands was found. However, area estimation requires the use of expensive ultrasound equipment or of a digitizing tablet. In both cases, area measurement is difficult owing to the irregular shape of the cistern.The aim of this study was to test the use of linear measurements taken directly from ultrasound images to estimate cistern size in dairy ewes.

URINARY RETENTION AFTER HYSTERECTOMY: SACRAL NEUROMODULATION TO RESTORE MICTURITION

A 44-year-old woman presented in nonobstructive urinary retention, which had developed after she had undergone hysterectomy for myoma of the uterus in January 1996. An indwelling catheter was placed for 1 week but overflow incontinence resumed after catheter removal. Residual urine was 600 to 1,000 ml. and the sensation of bladder filling was lost. Recurrent cystitis was accompanied by back and bladder pain when she tried to void. The frequency of bowel emptying, which had been every other day before hysterectomy, decreased to once a week and constipation developed. Excretory urography showed normal renal function without urinary obstruction. Neurological examination revealed irritation of the right plexus lumbosacralis with reduction of perianal and dermatomes Th12 and L1 sensitivity. Urodynamic evaluation demonstrated a bladder capacity of 1,000 ml. without bladder sensation or detrusor contraction, despite stimulation with rapid filling, coughing and intramuscular injection of 0.25 mg. carbachol. Maximal urethral closure pressure was 32 cm. water, and functional sphincteric length was 24 mm. Incontinence did not occur. Results of psychological evaluation were normal. Administration of 10 mg. bethanechol 3 times daily to strengthen the detrusor did not restore micturition, and the patient began clean intermittent self-catheterization. In June transurethral electrical bladder stimulation with continuous pulses of 10 Hz. for 1 hour at night, pulse duration 250 milliseconds and current less than 60 mA was performed for 4 weeks without success. Symptomatic cystitis recurred every 2 months for 2 years, despite antibiotics and careful clean intermittent catheterization. In October 1998 we tested percutaneous sacral neuromodulation. When the sacral spinal nerves S2, S3 and S4 on both sides were stimulated with 12 Hz., 2 to 5 V., a slight contraction of the levator ani muscle was elicited only with stimulation of the left spinal nerve of S3. During 3 days of test stimulation, the patient emptied the bladder completely. When stimulation was turned off near normal voiding ensued after 40 seconds (fig. 1). The voiding protocol indicated volumes of 200 to 800 ml. with residual volumes of less than 10%. When the test electrode was removed the patient was again unable to void. In December a permanent stimulator was implanted with the stimulating wire close to the left S3 spinal nerve (fig. 2). The stimulator (monopolar stimulation, 4.5 volts) was activated 3 days after implantation. With gradual cessation of back pain while in a sitting position (a consequence of surgery) the patient was increasingly able to relax the pelvic floor, resulting in complete bladder emptying. At followup in February 1999 urodynamic measurement during voiding revealed a detrusor contraction to 20 to 30 cm. water after the stimulator was turned off and the onset of voiding in about 1 minute. In April residual volumes of as much as 800 ml. and pain in the left buttock and thigh developed, and so stimulation was turned off. Initially electrode 1 was negative and the stimulator was positive. When electrode 3 was programmed to be negative the pain was gone and the stimulatAccepted for publication July 30, 1999. * Requests for reprints: Department of Urology, University of Munster, Albert Schweitzer Str. 33, 48129 Munster, Germany. FIG. 1. Micturition occurred after stimulation ceased

Preoperative Fasting in Children

Preoperative Fasting in Children