Accuracy of neurophysiological tests in patients with neurological diseases and pelvic floor symptoms: which tests for which patients
Main Article Content
Abstract
Aims. To evaluate the sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of neurophysiological tests in patients with neurological diseases and pelvic floor symptoms.
Methods.
Sixty-four of 111 outpatients who came to our attention for pelvic floor symptoms presented with neurological disorders (32 lower motor neuron disease [LMND], 30 upper motor neuron disease [UMND], 2 with mixed clinical picture). Forty-seven patients with chronic pelvic pain served as controls. All underwent neurological/perineal clinical evaluation and a battery of neurophysiological tests: concentric-needle electromyography (CNEMG) of external anal sphincter (EAS) muscle, pudendal evoked potentials (pPEPs), sacral reflexes, and perineal sympathetic skin response (pSSR). Upper and lower limits of normal values were collected and compared to patients' data. SE, SP, PPV, and NPV were calculated for each neurophysiological exam.
Results.
CNEMG of the EAS showed the highest SE, PPV, and NPV compared with the other tests in LMND; also in UMND, CNEMG of the EAS showed moderate SE and different patterns of abnormality. Combination of sacral reflexes and CNEMG increased the SE of single electrophysiological tests in LMND and UMND. PSEPs were altered in half of the patients with LMND and demonstrated high SE in UMND. PSSR had moderate SE in UMND but the lowest SP and PPV in patients with LMND or UMND.
Conclusions.
Targeted protocols including diverse neurophysiological tests should be chosen on the basis of neurological conditions and level of damage, while other tests should be used for research purposes.
Keywords:
Pelvic floor neurophysiology, Electromyography, Sacral reflexes, Pudendal evoked potentials, Perineal sympathetic skin response
Article Details
How to Cite
SQUINTANI, Giovanna et al.
Accuracy of neurophysiological tests in patients with neurological diseases and pelvic floor symptoms: which tests for which patients.
Medical Research Archives, [S.l.], v. 6, n. 5, may 2018.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/1778>. Date accessed: 23 dec. 2024.
doi: https://doi.org/10.18103/mra.v6i5.1778.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Enck P, Vodusek DB. Electromyography of pelvic floor muscles. J Electromyogr Kinesiol Off J Int Soc Electrophysiol Kinesiol 2006;16(6):568–77.
2. Olsen AL, Rao SS. Clinical neurophysiology and electrodiagnostic testing of the pelvic floor. Gastroenterol Clin North Am 2001;30(1):33–54.
3. Podnar S, Vodusek DB. Protocol for clinical neurophysiologic examination of the pelvic floor. Neurourol Urodyn 2001;20(6):669–82.
4. De Aguiar Cavalcanti G, Manzano GM, Nunes KF, Giuliano LMP, de Menezes TA, Bruschini H. Electrophysiological evaluation of the pudendal nerve and urethral innervation in female stress urinary incontinence. Int Urogynecology J 2013;24(5):801–7.
5. Lefaucheur JP. Neurophysiological testing in anorectal disorders. Muscle Nerve 2006;33(3):324–33.
6. Podnar S, Rodi Z, Lukanovic A, Trsinar B, Vodusek DB. Standardization of anal sphincter EMG: technique of needle examination. Muscle Nerve 1999;22(3):400-3.
7. Podnar S, Vodusek DB, Stålberg E. Comparison of quantitative techniques in anal sphincter electromyography. Muscle Nerve 2002;25(1):83-92.
8. Podnar S. Predictive values of the anal sphincter electromyography. Neurourol Urodyn 2009; 28(8):1034-5.
9. Podnar S. Criteria for neuropathic abnormality in quantitative anal sphincter electromyography. Muscle Nerve 2004;30(5):596-601.
10. Giladi N, Simon ES, Korczyn AD, Groozman GB, Orlov Y, Shabtai H, Drory VE. Anal sphincter EMG does not distinguish between multiple system atrophy and Parkinson’s disease. Muscle Nerve 2000;23(5):731–4.
11. Libelius R, Johansson F. Quantitative electromyography of the external anal sphincter in Parkinson’s disease and multiple system atrophy. Muscle Nerve 2000;23(8):1250–6.
12. Linder J, Libelius R, Nordh E, Holmberg B, Stenlund H, Forsgren L. Anal sphincter electromyography in patients with newly diagnosed idiopathic parkinsonism. Acta Neurol Scand 2012;126(4):248–55.
13. Tankisi H, Pugdahl K, Rasmussen MM, Clemmensen D, Rawashdeh YF, Christensen P, Krogh K, Fuglsang-Frederiksen A. Pelvic floor electrophysiology in spinal cord injury. Clin Neurophysiol 2016;127(5):2319-24.
14. Xiong GY, Zhao ZQ. Clinical significance of functional constipation categorized by colonic transit time and pelvic floor electromyography. Chin J Dig Dis 2004;5(4):156–9.
15. Andromanakos N, Skandalakis P, Troupis T, Filippou D. Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management. J Gastroenterol Hepatol 2006;21(4):638–46.
16. Pfeifer J, Teoh TA, Salanga VD, Agachan F, Wexner SD. Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients. Dis Colon Rectum 1998;41(9):1153-7.
17. Lacerda-Filho A, Lima MJ, Magalhães MF, Paiva Rde A, Cunha-Melo JR. Chronic constipation - the role of clinical assessment and colorectal physiologic tests to obtain an etiologic diagnosis. Arq Gastroenterol 2008;45(1):50-7.
18. Podnar S. Clinical and neurophysiologic testing of the penilo-cavernosus reflex. Neurourol Urodyn 2008 (a) 27(5):399-402.
19. Niu X, Shao B, Ni P, Wang X, Chen X, Zhu B, Wang Z, Teng H, Jin K.Bulbocavernosus reflex and pudendal nerve somatosensory-evoked potentials responses in female patients with nerve system diseases. J Clin Neurophysiol 2010;27(3):207-11.
20. Podnar S. Sphincter electromyography and the penilo-cavernosus reflex: are both necessary? Neurourol Urodyn 2008 (b); 27(8):813-8.
21. Podnar S. Utility of sphincter electromyography and sacral reflex studies in women with cauda equina lesions. Neurourol Urodyn 2014;33(4):426-30.
22. Krane RJ, Siroky MB. Studies on sacral-evoked potentials. J Urol 1980;124(6):872–6.
23. Podnar S. Sacral neurophysiologic study in patients with chronic spinal cord injury. Neurourol Urodyn 2011;30(4):587–92.
24. Jensen LN, Gerstenberg T, Kallestrup EB, Koefoed P, Nordling J, Nielsen JE. Urodynamic evaluation of patients with autosomal dominant pure spastic paraplegia linked to chromosome 2p21-p24. J Neurol Neurosurg Psychiatry 1998;65(5):693–6.
25. Koldewijn EL, Van Kerrebroeck PE, Bemelmans BL, Notermans SL, Lemmens WA, Debruyne FM.Use of sacral reflex latency measurements in the evaluation of neural function of spinal cord injury patients: a comparison of neuro-urophysiological testing and urodynamic investigations. J Urol 1994;152:463-7.
26. Yang CC, Bowen JD, Kraft GH, Uchio EM, Kromm BG. Physiologic studies of male sexual dysfunction in multiple sclerosis. Mult Scler Houndmills Basingstoke Engl 2001;7(4):249–54.
27. Niu X,Wang X, Ni P, Huang H, Zhang Y, Lin Y, Chen X, Teng H, Shao B. Bulbocavernosus reflex and pudendal nerve somatosensory evoked potential are valuable for the diagnosis of cauda equina syndrome in male patients. Int J Clin Exp Med 2015;8(1):1162-7.
28. Valles-Antuña C, Fernandez-Gomez J, Fernandez-Gonzalez F. Peripheral neuropathy: an underdiagnosed cause of erectile dysfunction. BJU Int 2011;108(11):1855-9.
29. Alves M, Conceição I, Luis ML. Neurophysiological evaluation of sexual dysfunction in familial amyloidotic polyneuropathy-Portuguese type. Acta Neurol Scand 1997;96(3):163-6.
30. Ashraf VV, Taly AB, Nair KP, Rao S, Sridhar. Role of clinical neurophysiological tests in evaluation of erectile dysfunction in people with spinal cord disorders. Neurol India 2005;53(1):32-5; discussion 35-6.
31. Rodi Z, Vodusek DB, Denislic M. Clinical uro-neurophysiological investigation in multiple sclerosis. Eur J Neurol 1996(b);3:574-580.
32. Seçil Y, Yetimalar Y, Gedizlioglu M, Arpaci E, Tokuçoglu F, Inceoglu Kendir A, Basoglu M, Ertelin C. Sexual dysfunction and sympathetic skin response recorded from the genital region in women with multiple sclerosis. Mult Scler Houndmills Basingstoke Engl 2007;13(6):742–8.
33. Schmid DM, Curt A, Hauri D, Schurch B. Clinical value of combined electrophysiological and urodynamic recordings to assess sexual disorders in spinal cord injured men. Neurourol Urodyn 2003;22(4):314–21.
34. Rodic B, Curt A, Dietz V, Schurch B. Bladder neck incompetence in patients with spinal cord injury: significance of sympathetic skin response. J Urol 2000;163(4):1223–7.
35. Ertekin C, Ertekin N, Mutlu S, Almis S, Akçam A.Skin potentials (SP) recorded from the extremities and genital regions in normal and impotent subjects. Acta Neurol Scand. 1987;76(1):28-36.
36. Ertekin C, Almis S, Ertekin N. Sympathetic skin potentials and bulbocavernosus reflex in patients with chronic alcoholism and impotence. Eur Neurol 1990;30(6):334–7.
37. Seçil Y, Ozdedeli K, Altay B, Aydoğdu I, Yilmaz C, Ertekin C. Sympathetic skin response recorded from the genital region in normal and diabetic women. Neurophysiol Clin Clin Neurophysiol 2005;35(1):11–7.
38. Lefaucheur JP, Yiou R, Colombel M, Chopin DK, Abbou CC. Relationship between penile thermal sensory threshold measurement and electrophysiologic tests to assess neurogenic impotence. Urology 2001;57(2):306–9.
39. Sau GF, Aiello I, Siracusano S, Belgrano M, Pastorino M, Balsamo P, Magnano I, Rosati G. Pudendal nerve somatosensory evoked potentials in probable multiple sclerosis. Ital J Neurol Sci 1997;18(5):289-91.
40. Ghezzi A, Malvestiti GM, Baldini S, Zaffaroni M, Zibetti A. Erectile impotence in multiple sclerosis: a neurophysiological study. J Neurol 1995;242(3):123–6.
41. Podnar S, Vodusek DB. Standardization of anal sphincter electromyography: effect of chronic constipation. Muscle Nerve 2000;23(11):1748-51.
2. Olsen AL, Rao SS. Clinical neurophysiology and electrodiagnostic testing of the pelvic floor. Gastroenterol Clin North Am 2001;30(1):33–54.
3. Podnar S, Vodusek DB. Protocol for clinical neurophysiologic examination of the pelvic floor. Neurourol Urodyn 2001;20(6):669–82.
4. De Aguiar Cavalcanti G, Manzano GM, Nunes KF, Giuliano LMP, de Menezes TA, Bruschini H. Electrophysiological evaluation of the pudendal nerve and urethral innervation in female stress urinary incontinence. Int Urogynecology J 2013;24(5):801–7.
5. Lefaucheur JP. Neurophysiological testing in anorectal disorders. Muscle Nerve 2006;33(3):324–33.
6. Podnar S, Rodi Z, Lukanovic A, Trsinar B, Vodusek DB. Standardization of anal sphincter EMG: technique of needle examination. Muscle Nerve 1999;22(3):400-3.
7. Podnar S, Vodusek DB, Stålberg E. Comparison of quantitative techniques in anal sphincter electromyography. Muscle Nerve 2002;25(1):83-92.
8. Podnar S. Predictive values of the anal sphincter electromyography. Neurourol Urodyn 2009; 28(8):1034-5.
9. Podnar S. Criteria for neuropathic abnormality in quantitative anal sphincter electromyography. Muscle Nerve 2004;30(5):596-601.
10. Giladi N, Simon ES, Korczyn AD, Groozman GB, Orlov Y, Shabtai H, Drory VE. Anal sphincter EMG does not distinguish between multiple system atrophy and Parkinson’s disease. Muscle Nerve 2000;23(5):731–4.
11. Libelius R, Johansson F. Quantitative electromyography of the external anal sphincter in Parkinson’s disease and multiple system atrophy. Muscle Nerve 2000;23(8):1250–6.
12. Linder J, Libelius R, Nordh E, Holmberg B, Stenlund H, Forsgren L. Anal sphincter electromyography in patients with newly diagnosed idiopathic parkinsonism. Acta Neurol Scand 2012;126(4):248–55.
13. Tankisi H, Pugdahl K, Rasmussen MM, Clemmensen D, Rawashdeh YF, Christensen P, Krogh K, Fuglsang-Frederiksen A. Pelvic floor electrophysiology in spinal cord injury. Clin Neurophysiol 2016;127(5):2319-24.
14. Xiong GY, Zhao ZQ. Clinical significance of functional constipation categorized by colonic transit time and pelvic floor electromyography. Chin J Dig Dis 2004;5(4):156–9.
15. Andromanakos N, Skandalakis P, Troupis T, Filippou D. Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management. J Gastroenterol Hepatol 2006;21(4):638–46.
16. Pfeifer J, Teoh TA, Salanga VD, Agachan F, Wexner SD. Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients. Dis Colon Rectum 1998;41(9):1153-7.
17. Lacerda-Filho A, Lima MJ, Magalhães MF, Paiva Rde A, Cunha-Melo JR. Chronic constipation - the role of clinical assessment and colorectal physiologic tests to obtain an etiologic diagnosis. Arq Gastroenterol 2008;45(1):50-7.
18. Podnar S. Clinical and neurophysiologic testing of the penilo-cavernosus reflex. Neurourol Urodyn 2008 (a) 27(5):399-402.
19. Niu X, Shao B, Ni P, Wang X, Chen X, Zhu B, Wang Z, Teng H, Jin K.Bulbocavernosus reflex and pudendal nerve somatosensory-evoked potentials responses in female patients with nerve system diseases. J Clin Neurophysiol 2010;27(3):207-11.
20. Podnar S. Sphincter electromyography and the penilo-cavernosus reflex: are both necessary? Neurourol Urodyn 2008 (b); 27(8):813-8.
21. Podnar S. Utility of sphincter electromyography and sacral reflex studies in women with cauda equina lesions. Neurourol Urodyn 2014;33(4):426-30.
22. Krane RJ, Siroky MB. Studies on sacral-evoked potentials. J Urol 1980;124(6):872–6.
23. Podnar S. Sacral neurophysiologic study in patients with chronic spinal cord injury. Neurourol Urodyn 2011;30(4):587–92.
24. Jensen LN, Gerstenberg T, Kallestrup EB, Koefoed P, Nordling J, Nielsen JE. Urodynamic evaluation of patients with autosomal dominant pure spastic paraplegia linked to chromosome 2p21-p24. J Neurol Neurosurg Psychiatry 1998;65(5):693–6.
25. Koldewijn EL, Van Kerrebroeck PE, Bemelmans BL, Notermans SL, Lemmens WA, Debruyne FM.Use of sacral reflex latency measurements in the evaluation of neural function of spinal cord injury patients: a comparison of neuro-urophysiological testing and urodynamic investigations. J Urol 1994;152:463-7.
26. Yang CC, Bowen JD, Kraft GH, Uchio EM, Kromm BG. Physiologic studies of male sexual dysfunction in multiple sclerosis. Mult Scler Houndmills Basingstoke Engl 2001;7(4):249–54.
27. Niu X,Wang X, Ni P, Huang H, Zhang Y, Lin Y, Chen X, Teng H, Shao B. Bulbocavernosus reflex and pudendal nerve somatosensory evoked potential are valuable for the diagnosis of cauda equina syndrome in male patients. Int J Clin Exp Med 2015;8(1):1162-7.
28. Valles-Antuña C, Fernandez-Gomez J, Fernandez-Gonzalez F. Peripheral neuropathy: an underdiagnosed cause of erectile dysfunction. BJU Int 2011;108(11):1855-9.
29. Alves M, Conceição I, Luis ML. Neurophysiological evaluation of sexual dysfunction in familial amyloidotic polyneuropathy-Portuguese type. Acta Neurol Scand 1997;96(3):163-6.
30. Ashraf VV, Taly AB, Nair KP, Rao S, Sridhar. Role of clinical neurophysiological tests in evaluation of erectile dysfunction in people with spinal cord disorders. Neurol India 2005;53(1):32-5; discussion 35-6.
31. Rodi Z, Vodusek DB, Denislic M. Clinical uro-neurophysiological investigation in multiple sclerosis. Eur J Neurol 1996(b);3:574-580.
32. Seçil Y, Yetimalar Y, Gedizlioglu M, Arpaci E, Tokuçoglu F, Inceoglu Kendir A, Basoglu M, Ertelin C. Sexual dysfunction and sympathetic skin response recorded from the genital region in women with multiple sclerosis. Mult Scler Houndmills Basingstoke Engl 2007;13(6):742–8.
33. Schmid DM, Curt A, Hauri D, Schurch B. Clinical value of combined electrophysiological and urodynamic recordings to assess sexual disorders in spinal cord injured men. Neurourol Urodyn 2003;22(4):314–21.
34. Rodic B, Curt A, Dietz V, Schurch B. Bladder neck incompetence in patients with spinal cord injury: significance of sympathetic skin response. J Urol 2000;163(4):1223–7.
35. Ertekin C, Ertekin N, Mutlu S, Almis S, Akçam A.Skin potentials (SP) recorded from the extremities and genital regions in normal and impotent subjects. Acta Neurol Scand. 1987;76(1):28-36.
36. Ertekin C, Almis S, Ertekin N. Sympathetic skin potentials and bulbocavernosus reflex in patients with chronic alcoholism and impotence. Eur Neurol 1990;30(6):334–7.
37. Seçil Y, Ozdedeli K, Altay B, Aydoğdu I, Yilmaz C, Ertekin C. Sympathetic skin response recorded from the genital region in normal and diabetic women. Neurophysiol Clin Clin Neurophysiol 2005;35(1):11–7.
38. Lefaucheur JP, Yiou R, Colombel M, Chopin DK, Abbou CC. Relationship between penile thermal sensory threshold measurement and electrophysiologic tests to assess neurogenic impotence. Urology 2001;57(2):306–9.
39. Sau GF, Aiello I, Siracusano S, Belgrano M, Pastorino M, Balsamo P, Magnano I, Rosati G. Pudendal nerve somatosensory evoked potentials in probable multiple sclerosis. Ital J Neurol Sci 1997;18(5):289-91.
40. Ghezzi A, Malvestiti GM, Baldini S, Zaffaroni M, Zibetti A. Erectile impotence in multiple sclerosis: a neurophysiological study. J Neurol 1995;242(3):123–6.
41. Podnar S, Vodusek DB. Standardization of anal sphincter electromyography: effect of chronic constipation. Muscle Nerve 2000;23(11):1748-51.