INCONTINENCE IN NEUROPATHIC PATIENTS
XIV. HERPES ZOSTER
2. PATHOLOGY AND DISEASE SPECIFIC LUT PROBLEMS
As already described virtually all parts of the body could by involved in AIDS patients ,either as the primary location of HIV infection or secondary to HIV- related complications.
Among these different manifestations particular attention should be paid to the primary locations as they develop early in the stage of the disease.
HTLV-I associated myelopathy (HAM) affects up to 3% of HIV positive patients and is manifested by slowly progressive spastic paraparesis, including deterioration of bladder problems ( LOE 2). Another interesting primary demonstration of HIV infection is lumbosacral polyradiculopathy, described by Matsumoto et al (LOE 3). In this case report voiding difficulties and lower limb paresis were the primary manifestation of HIV infection.
Also Mahieux et al ( LOE 3) described a case of acute myeloradiculitis due to cytomegalovirus as the initial manifestation of terminal stage .
Begara et al (LOE 3) performed urodynamic studies in 10 patients with AIDS and voiding disorders and found that the most common symptom was urge incontinence and the most common urodynamic finding was detrusor-external sphincter dyssynergia . In 3 patients they found demonstrable functional disorders of the LUT (2 patients had detrusor ove- ractivity: one of them had a history of encephalopathy from HIV and the other patient had polyneuritis; the third patient had myelitis and a urodynamically diagnosed sympathetic decentralization. Detrusor areflexia was described in 2 HIV-positive patients by Menendez et al (LOE 3). One of them had an ascending myelitis of probable herpetic origin, the other had a cerebral abscess caused by Toxoplasma gondii.
3. DISEASE SPECIFIC DIAGNOSIS AND TREATMENT
Since during the course of the disease all parts of the nervous system can be involved, either as the primary location or secondary to AIDS-related complications, no disease specific diagnosis or treatment can be proposed. It is important to observe that sometimes functional disorders of the LUT can be the first manifestation of the HIV infection.
When managing the patient with HIV infection one must bear in mind that both storage and voiding problems can occur and that both should be treated according to the results of urodynamic studies.
4. GUIDELINES FOR FURTHER RESEARCH
All rapports about HIV and voiding problems are rather anecdotal and no good prospective studies exist. The
need for such studies is particularly important, when realizing that it takes up to 20-30 years from HIV infection to AIDS full manifestation and that new antiviral treatment modalities could prolong the life of a patient with HIV significantly.
Particular attention should be paid to primary nervous system involvement by HIV and to related voiding dysfunction as well as to the voiding dysfunctions that could be the side effects of HIV drug therapy.
5. FAECAL INCONTINENCE
As diarrhoea is common in HIV infected patients, the faecal incontinence can also occur, mostly due to anal sphincter weakness. Again the true incidence of HIV neuropathy relatad faecal incontinence is not known and further studies are needed , (LOE 4) CONCLUSIONS
• Patients with HIV and nervous system
pathological signs and symptoms should be evaluated towards functional LUT problems ( B)
• Due to the variety of LUT functional damage
in HIV patients urodynamic study is essential for tailoring the optimal therapy ( C)
• No HIV specific therapy of LUT problems
and faecal incontinence exist. Due to variety of functional damage therapy should be individually tailored, accordingly to the results of functional/imaging studies (C)
• HIV can influence the nervous system and
the LUT functions in two ways: as primary infection site or secondary to AIDS related complications (LOE2/3)
• Nervous system manifestation of HIV
infection can by the only sign and it is therefore important to take the possibility of HIV infection into consideration when facing unusual signs and symptoms from the LUT without any other obvious cause (LOE 3)
• HIV/AIDS is a progressive disease and
dynamic changes to the LUT functions can occur during the evoluation of the disease (LOE 2)
• Faecal incontinence in HIV/AIDS patients is
usually associated with diarrhoea, however the true incidence is not known (LOE 4)
1. Nievelstein RA, van der Werff JF, Verbeek FJ, Valk J,Vermeij- Keers, C..: Normal and abnormal embryonic development of the anorectum in human embryos. Teratology 1998; 57: 70- 78
2. Valentino R J, Miselis R R, Pavcovich L A. Pontine regulation of pelvic viscera: pharmacological target for pelvic visceral dysfunctions. Trends Pharmacol Sci 1999; 20: 253- 260 3. Fowler C J.The perspective of a neurologist on treatment-
related research in fecal and urinary incontinence. Gastroenterology 2004; 126 S1: 172-174
4. De Wachter S, Wyndaele J J. Impact of rectal distention on the results of evaluations of LUT sensation. J Urol 2003; 169: 1392-1394
5. Shafik A. The effect of vesical filling and voiding on the anorectal function with evidence of a 'vesico-anorectal reflex'. Neurogastroenterol Motil 1999; 11: 119 -124
6. De Wachter S, de Jong A, Van Dyck J, Wyndaele JJ. Interaction of filling related sensation between anorectum and lower urinary tract and its impact on the sequence of their evacuation. A study in healthy volunteers. Neurourol Urodyn. 2007; 26: 481-485
7. Siroky M B, Krane R J. Neurologic aspects of detrusor- sphincter dyssynergia, with reference to the guarding reflex. J Urol 1982; 127: 953-957.
8. Brocklehurst J C, Andrews K, Richards B, Laycock PJ. Incidence and correlates of incontinence in stroke patients. J Am Geriatr Soc 1985; 33: 540-542
9. Wyndaele J J. Correlation between clinical neurological data and urodynamic function in spinal cord injured patients. Spinal Cord 1997; 35: 213-216.
10. Wyndaele J J, De Sy W A. Correlation between the findings of a clinical neurological examination and the urodynamic dysfunction in children with myelodysplasia. J Urol 1985; 133: 638 -640.
1. Andrew J, Nathan PW. Lesions of the anterior frontal lobes and disturbances of micturition and defecation. Brain 1964; 87: 233-262.
2. Maurice-Williams, R. S.: Micturition symptoms in frontal tumours. J Neurol Neurosurg Psychiatry. 1974; 37: 431-436 3. Lang, E. W., Chesnut, R. M., Hennerici, M.: Urinary retention and space-occupying lesions of the frontal cortex. Eur Neurol. 1996;36:43-47
4. Ueki K. Disturbances of micturition observed in some patients with brain tumor. Neurol Med Chir 1960; 2: 25-33. 5. Renier WO, Gabreels FJ. Evaluation of diagnosis and non-
surgical therapy in 24 children with a pontine tumour. Neuropediatrics 1980; 11: 262-73.
6. Toba K, Ouchi Y, Orimo H, Iimura O, Sasaki H, Nakamura Y, Takasaki M, Kuzuya F, Sekimoto H, Yoshioka H, Ogiwara T, Kimura I, Ozawa T, Fujishima M.. Urinary incontinence in elderly inpatients in Japan: a comparison between general and geriatric hospitals. Aging (Milano ) 1996; 81:47-54. 7. Campbell AJ, Reinken J, McCosh L. Incontinence in the
elderly: prevalence and prognosis. Age Ageing 1985; 142:65- 70.
8. Horimoto Y, Matsumoto M, Akatsu H, Ikari H, Kojima K, Yamamoto T, Otsuka Y, Ojika K, Ueda R, Kosaka K. Autonomic dysfunctions in dementia with Lewy bodies. J Neurol 2003; 250(5):530-533.
9. Sugiyama T, Hashimoto K, Kiwamoto H, Ohnishi N, Esa A, Park YC, Kurita T. Urinary incontinence in senile dementia of the Alzheimer type (SDAT). Int J Urol 1994;1:337-340. 10. McGrother C, Resnick M, Yalla SV, Kirschner-Hermanns R,
Broseta E, Muller C, Welz-Barth A, Fischer GC, Mattelaer J, McGuire EJ. Epidemiology and etiology of urinary