Bulbar sexual dysfunction-

However, there are still some controversies regarding the optimal technique and the consequences of transecting the urethra in terms of sexual dysfunction, such as erectile dysfunction, penile shortening, impaired glans filling, decreased glans sensibility and ejaculatory function. We performed a retrospective analysis with long-term followup of anastomotic and substitution onlay urethroplasty in bulbar strictures with an emphasis on postoperative sexual function. Mean followup in the transection and onlay groups was 41 and 69 months, respectively range 12 to All patients were asked verbally about sexual function during followup. Failure was defined as the need for new surgical intervention.

Bulbar sexual dysfunction

Bulbar sexual dysfunction

Bulbar sexual dysfunction

Bulbar sexual dysfunction

The etiology of urethral stricture disease is multifactorial and includes trauma, inflammatory, and iatrogenic causes. Patients were asked to read 3 standard passages from the Thai Nasality Test. This technique preserves the remaining urethral plate and avoids the use of a wide single dorsal or ventral graft. Sixty percent remained Bublar and of these almost all 64 of 66 patients remained potent after posterior urethroplasty. Penile duplex doppler ultrasound documented that When appropriate, comparisons were made between the transecting and nontransecting cohorts using the Mantel-Cox test, Bulbar sexual dysfunction t-test or the chi-square test. Before the urethroplasty operation and postoperative 6th month follow-up, the international index of erectile function IIEF form 15 questions Steel and chain bondage model, was filled, the relevant domains of sexual function; erectile function Q1,2,3,4,5,15orgasmic function Q9,10 and overall satisfaction Q13,14 were assessed. However, Bulbar sexual dysfunction did not interfere with sexual ability during intercourse.

Girl getting analed. Introduction

Lips - produce mb and p. The motor aspects of speech, like other movements, are also influenced by the extrapyramidal system via the basal Spider-man shirt adult and the Bulbar sexual dysfunction. A speech therapist can also help a long way in aiding the patient to speak better as speech is also severely affected due to Bulbar Palsy. Doppler results help guide the clinician's treatment and predict response rates. The success rate of She took about an hour to complete a feed and this was associated with choking, spluttering, and coughing. E-mail: moc. The trial of neostigmine led to a marked clinical improvement with increased energy and stronger vocalization along with improved chewing and swallowing abilities. Study No. Forgot your username? In addition, there may be lower motor neuron lesions of the limbs. Bulbar palsy Bulbar sexual dysfunction sometimes also classified as non-progressive or progressive.

N ormal pressure hydrocephalus NPH is a syndrome characterized by gait disturbance, cognitive impairment, and urinary incontinence, as well as enlargement of the ventricles, which results from disturbance of CSF circulation in a setting of normal CSF pressure.

  • To evaluate alterations in sexual function and genital sensitivity after anastomotic repair AR and free graft urethroplasty FGU for bulbar urethral strictures.
  • Professional Reference articles are designed for health professionals to use.
  • Bulbar palsy refers to a range of different signs and symptoms linked to impairment of function of the cranial nerves 9, 10, 11, 12, which occurs due to a lower motor neuron lesion in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.
  • Bulbar Palsy also known as Progressive Bulbar Palsy is a pathological condition in which the nerve cells which are responsible for movement get affected.
  • Congenital myasthenic syndromes are a group of rare genetic disorders affecting neuromuscular transmission.

The effect of urethroplasty surgery on erectile and orgasmic functions: a prospective study. Ozgur H. Yuksel 2. Metin I. Ozturk 1. The prospective study was conducted between January and August with 60 cases. Before the urethroplasty operation and postoperative 6th month follow-up, the international index of erectile function IIEF form 15 questions , was filled, the relevant domains of sexual function; erectile function Q1,2,3,4,5,15 , orgasmic function Q9,10 and overall satisfaction Q13,14 were assessed.

However, preoperative IIEF, sexual satisfaction and orgasmic function averages of patients with a stenosis segment length of cm was found to be significantly higher than that of patients with a stenosis segment length of cm. Between stenosis segment length groups, there was no statistical difference in terms of preoperative and postoperative sexual functions.

However, there were statistically significant change in the postoperative IIEF and sexual satisfaction averages according to preoperative averages. Our study suggests that urethroplasty surgery itself does not significantly affect erectile function, orgasmic function, and general sexual satisfaction regardless of the type of surgery, localization and length of stenosis.

Besides, there was a significant decrease in erectile function in senior adults. Urethral stricture refers to the scar formation involving the spongiformis erectile tissue of the corpus spongiosum, resulting in a concomitant narrowing of the urethral lumen.

The process leading to this fibrosis is primarily subepithelial inflammation and hemorrhage and later stages are characterized with sclerosis and fibrosis.

Posterior urethral injuries are often associated with pelvic fractures. Treatment alternatives include; dilatation, internal urethrotomy, laser treatments, and open reconstruction.

In the past, known as the reconstructive ladder, it has always been suggested that the simplest procedure should always be tried in the first stage, and in case of failure, proceeding to more complex approaches is recommended in guidelines. In modern urethral reconstruction, this approach is considered outdated. Even in some studies it has been shown that recurrent dilatations and internal urethrotomies reduce the success rate of ultimate open urethral reconstruction 1 , 2.

Certainly there are also strictures that require tissue transfer; grafts and flaps are successfully deployed here 3 , 4. In addition to psychogenic factors, erectile dysfunction ED after urethroplasty may be due to damage to the cavernous nerve, damage to the perineal nerve, and deterioration of the flow of the bulbar artery. In order to reduce this damage, it is suggested to protect bulbospongiosus muscle and peroneal nerves, not to cut central tendon, not to damage the bulbar artery, use buccal mucosal graft without cutting corpus spongiosum 5 — 7.

The neurovascular structures responsible for the erectile function pass from a distance of approximately 3 mm from clockwise 1 and 11 right outside the corpus spongiosum and some branches from the cavernous nerves enter the corpus spongiosum across the entire penis.

The intercranial area shows that this vessel and nerve bundle is unprotected and vulnerable to trauma. For this reason, the bulb can be very easily damaged during the dissection of the urethra 8 — Another important point for this region is the damage of the perineal nerve during the separation of the bulbospongiosus muscle on the corpus spongiosum. It provides semen expulsion and sense of penile ventral surface In addition to the effect of the perineal nerve on ejaculation, there is also an effect on erectile function.

For this reason, the perineal nerve is thought to be an extra neural pathway for erectile function through unrecognized reflex mechanisms. To protect erectile functions after urethroplasty, it would be beneficial to preserve this neural tissue, if possible 12 , In this study, we examined the effects of urethroplasty surgery on sexual functions by taking into account age, location of stenosis, length of stenosis and surgical technique parameters and we hypothesized that location and length of stricture and type of urethroplasty is not affecting sexual functions but older age may affect postoperative sexual functions.

Following ethical board approval, the prospective study was conducted between January and August with 60 cases aged between 19 and 75 years.

And also, patients with a history of coronary artery bypass graft surgery, unregulated hypertension and diabetes were excluded from the study. Only six patients with 2 cm stricture at bulbar urethra, had undergone endoscopic intervention once before and failed.

All urethroplasty operations were performed by the same surgeon experienced in reconstructive urology. All patients were evaluated with anamnesis, history, physical examination, urine analysis and culture, uroflowmetry, retrograde urethrography before surgery. Before the open urethroplasty operation and postoperative 6th month follow-up, the international index of erectile function IIEF form 15 questions was filled, the relevant domains of sexual function; erectile function Q, 15 , orgasmic function Q9, 10 and overall satisfaction Q13, 14 were assessed.

The technique of the surgery, localization of the stricture and the length of the narrow segment were also noted. Urethroplasty was applied for bulbar and penile urethral strictures.

This series includes excision and end - to - end anastomoses using both transecting and non - transecting technique , dorsal onlay buccal mucosal graft, ventral inlay buccal mucosal graft and penile skin flap cases. During operation, surgeon prone to keep the dissection area as small as possible at the bulbar urethral level and did not used cautery during the dissection.

And also, surgeon tried to protect bulbospongiosus muscle and peroneal nerves, not to cut central tendon, not to damage the bulbar artery, and used buccal mucosal graft without cutting corpus spongiosum. When the study data were evaluated, the normal distribution of the parameters was assessed by the Shapiro Wilks test.

When study data were evaluated; Kruskal Wallis test was used in comparing quantitative data for comparison of parameters without normal distribution as well as descriptive statistical methods mean, standard deviation, frequency.

Student's t test was used to compare parameters with normal distribution between two groups and Mann Whitney U test was used to compare parameters without normal distribution between two groups. Paired Sample t test was used for intra - group comparison of quantitative data showing normal distribution, Wilcoxon Signed Ranks test was used for intra - group comparison of parameters without normal distribution. The prospective study was conducted between January and August with 60 cases aged between 19 and 75 years.

The mean age of the cases was The stricture segment lengths ranged from 2 to 7 cm, with a mean of 3. In Preoperative IIEF values of the patients ranged from 8 to 29, with a mean of Preoperative IIEF, sexual satisfaction and orgasmic function averages of patients with a stricture segment length of cm was found to be significantly higher than that of patients with a stricture segment length of cm p: 0.

According to age groups, preoperative sexual satisfaction averages of those aged 65 and below were statistically significantly higher than those of older than 65 years p: 0. However, there were no statistically significant difference in the mean preoperative IIEF and orgasmic function p: 0.

Again, postoperative IIEF, sexual satisfaction and orgasmic function averages of those aged 65 and below were found to be statistically significantly higher than those of those older than 65 years p: 0. However, there were statistically significant change in the postoperative IIEF and sexual satisfaction averages according to preoperative averages p: 0.

Sexual dysfunction after urethroplasty is a very broad definition that also includes disorders of erectile dysfunction, ejaculatory disorders, penile curvature or chordee and genital sensitivity disorders. In some studies it was thought that the age of the patient, pre - surgical sexual function, previous surgical intervention, post - operative survival, length of stenosis and severity of stricture might be factors affecting long - term erectile function after urethroplasty 14 — The first article on continuous ED development after urethroplasty was written by Mundy et al.

The relationship between ED after the urethroplasty and the patient's age was different in different studies. A study by Johannes and his colleagues found that the ED frequency decreased as the age of the patients decreased. In another study, it was shown that patient age is important in improving ED after urethroplasty. It was stated that the time required for complete recovery of erectile function after surgery in patients under 40 years is 6 months In a prospective study conducted by Erickson et al.

They stated that bulbar urethroplasty can affect erectile function more than penile urethroplasty and this can be explained with the fact that bulbar urethra is located closer to the nerve responsible for the erection Haines et al. This relationship has also been explained by reduced tissue plasticity, poor recovery, or perhaps even more co - morbidity of the elderly cohort, and thus greater susceptibility to ED development There are studies that show that age has a little effect on urinary and sexual functions after urethroplasty as opposed to these In our study, patients were evaluated in two different groups including patients younger than 65 years of age and patients older than 65 years of age.

In patients younger than 65 years of age, there was no statistically significant difference in terms of preoperative and postoperative sexual functions. However, in patients older than 65 years of age, there were statistically significant difference in the postoperative IIEF and sexual satisfaction averages according to preoperative averages. In addition, while there was no significant difference between age groups in terms of preoperative IIEF and orgasmic functions, there was a statistically significant difference between the two groups in the postoperative averages.

Although we cannot make an optimal assessment because of the small number of patients in this group of older than 65 years, these results suggest that the senior adult group may be more affected by urethroplasty surgery in terms of sexual functions. When studies were examined, the type of urethroplasty applied was thought to be effective in the formation of ED. In a study involving eighty - nine patients, patients were divided into 3 groups according to urethroplasty.

Penile substitution urethroplasty, bulbar excision - anastomosis and bulbar substitution urethroplasty were compared. Average follow-up time was 15 months. Stricture length and patient age were statistically similar in all groups. The authors noted that the type of urethroplasty applied did not have a significant effect on the development of ED and that erectile function after urethroplasty was improved within the first 6 months.

The same authors also recommended early use of phosphodiesterase type — 5 inhibitors and nonsteroidal anti-inflammatory drugs In the literature review of Dogra et al. Along with similar studies in the literature, Haines et al. In our study, there was no statistically significant difference for preoperative and postoperative IIEF scores, orgasmic function and sexual satisfaction according to stenosis localization and surgery type.

Initially, de novo ED after urethroplasty was shown to be higher in elderly patients and those with long stricture segments 6. Further work, however, has disproved this relationship. And in a recent meta - analysis, no relationship was found between the length of stricture and the incidence of postoperative ED 6 , According to Coursey et al.

In our study, although the preoperative erectile function of the patients with the long stricture segment was lower than the patients with the short stricture segment cm , there was no significant change in the erectile function of these patients in the postoperative period. Erickson et al. However, older men reported that they had more ED after the surgery than younger men, but that erectile function probably improved over time In our study, in terms of preoperative IIEF, orgasmic function and sexual satisfaction, there were statistically significant differences between the stricture length groups of cm and cm.

Also, there were significant differences both preoperative and postoperative scores between the age groups of below and above The length of the urethral stricture is closely related to the grade of fibrosis in the urethra and surrounding tissues. Among the causes of long urethral strictures it is included inflammatory diseases, recurrent urethral dilatations, long - term urethral catheterizations, and traumatic urethral injuries.

In the literature review of Palminteri et al. Our study includes some limitations although it has a prospective design. A single surgeon in a single center conducted all of the urethroplasties. But it is acceptable to consider that surgical techniques and stricture etiology may significantly affect to the outcomes. Consequently, this may limit the generalizability of our results.

Chronic pain is the result of an injury or malfunction of peripheral pain receptors or central nervous system. The individual affected with Bulbar Palsy will experience symptoms like:. Volume 3 , Issue 3. The tests to diagnose liver metastases are the following: CT or MR Magnetic Resonance , liver function tests, liver ultrasound and liver biopsy. The male urethra is divided into four parts: prostatic, membranous, bulbar, and penile urethra. The success rate of

Bulbar sexual dysfunction

Bulbar sexual dysfunction

Bulbar sexual dysfunction

Bulbar sexual dysfunction

Bulbar sexual dysfunction. What Causes Bulbar Palsy?

The aim of this paper is to evaluate and compare sexual function after AR and FGU for bulbar strictures in a prospective fashion. Out of male patients who underwent urethroplasty between October and February , 90 patients with a bulbar stricture only were planned to be treated with AR or FGU and eligible to participate in this prospective study. Prepuce and oral mucosa was used as graft in, respectively, 12 and 4 patients. Stricture location and stricture length were evaluated by retrograde urethrography.

This study included the following evaluations:. Patients were evaluated preoperatively, after 6 weeks and 6 months. In the first six months, no phosphodiesterase-5 inhibitors were prescribed to stimulate sexual rehabilitation. A functional definition of failure was used which includes the need for any additional urethral manipulation including dilation [ 11 ]. For longer strictures, FGU was performed. For both techniques, a midline perineal incision is made; the bulbospongiosus muscle is incised at the midline and dissected away from the corpus spongiosum.

In case of AR, the corpus spongiosum is circumferentially freed at the level of the stricture. The corpus spongiosum and urethra are transected at this site. The fibrotic urethra and spongiosus edges are resected until healthy urethra is present at both the distal and proximal ends. The urethra is then spatulated in order to obtain a broad oblique anastomosis, which is finalized by 8—10 interrupted resorbable 4.

In case of FGU, the stricture is opened ventrally on the tip of the catheter. The stricture length is measured and a graft is taken accordingly. The graft is sutured into the urethra in a ventral onlay fashion. The corpus spongiosum is closed over the graft for vascular supply and mechanical support spongioplasty.

The urethral catheter is maintained for 14 days and a voiding cystourethrogram is made upon removal. Descriptive statistics were performed to evaluate the whole population and both subgroups.

To compare both groups, continuous variables were evaluated by independent-samples t -test or the Welch modified t -test for, respectively, equal and unequal distributions. Categorical variables were evaluated by chi-square or Fischer's exact test. The 2-year recurrence-free survival was estimated by Kaplan-Meier statistics and groups were compared by log rank statistics. After a mean follow-up of 23 months, 6 patients Overall and in both groups, there was a significant improvement of the urinary flow at latest follow-up.

Accordingly, there was a significant improvement in IPSS after 6 weeks and 6 months overall and in both groups Table 2 ; Figure 2 a. After 6 months, EOS returned to baseline. At 6 weeks and 6 months, respectively, 45 and 25 patients filled in the questionnaire on genital sensitivity and on cold feeling in the glans. At 6 weeks, 28 patients Only one patient, treated by AR, had a cold feeling in the glans.

At 6 months, no one reported a cold feeling in the glans. Of the 4 patients treated with oral mucosa, 2 had altered genital sensitivity and no glans tumescence at 6 weeks and 6 months. Although this series is a prospective study, no randomization was done between AR and FGU because the use of AR is limited by the stricture length. This also explains why strictures treated with AR were significantly shorter compared to FGU in this series.

Another difference between both groups was younger patient's age with AR. For this observation, we have the following explanation: patients treated with AR have shorter strictures cf. Despite these differences in age and stricture length between AR and FGU, preoperative erectile and orgasmic function was not significantly different between these groups.

It has been reported that longer stricture length and more advanced patient age are more likely to be associated with postoperative erectile dysfunction ED [ 14 — 16 ]. The observed difference in patient age and stricture length would thus be in favor of AR in terms of postoperative erectile function. This has not been observed in this series, on the contrary. The success rate of For longer strictures at the bulbar urethra, FGU is the preferred technique of substitution urethroplasty as flaps are associated with more morbidity [ 3 ].

Our This recommendation is questioned because of a potential higher risk of sexual dysfunction related to AR [ 17 ]. An increasing number of papers report on sexual dysfunction after urethroplasty [ 6 — 8 , 18 ]. Although the results are far from uniform, there is a trend for a higher incidence of sexual dysfunction after AR compared to FGU.

Palminteri et al. This is in line with our results revealing a trend to improvement in erectile and orgasmic function in the FGU-group. In their prospective study, Erickson et al. However, these differences were not statistically significant [ 7 ]. In their logistic regression model, Xie et al. Other authors did not find a significant decline in erectile function [ 19 , 20 ] nor did they find a difference between AR and FGU [ 15 , 16 , 21 , 22 ]. These contradictory results can be explained by several factors.

First, timing of evaluation seems to be very important. Erickson et al. Xie et al. In the AR-group, we also found a transient decline in erectile function after 6 weeks with recuperation after 6 months.

Secondly, the evaluation tool to assess erectile function might be important. The IIEF-5 is a validated questionnaire to assess erectile function and was therefore used in this series. Other authors, however, used an in-house questionnaire with dichotomous answers erectile dysfunction present or absent [ 16 , 19 , 22 ]. Other factors that might be important to explain contradictory findings among studies are retrospective evaluation with risk of recall bias [ 9 , 16 , 19 , 22 ] and small patient groups [ 21 ].

We speculate that the observed transient decline in erectile function with AR might be related to the following:. In this series, ventral FGU was performed, with no significant decrease in sexual functioning at 6 weeks and 6 months.

It would be interesting to know whether dorsal FGU affects sexual functioning. One would expect a higher incidence of sexual dysfunction if the hypothesis of more extensive and circumferential dissection of the bulbar corpus spongiosum is in part responsible for sexual dysfunction.

Improvement of ejaculatory function after urethroplasty might be related to desobstruction of the urethra [ 26 ]. However this cannot explain the transient decline in ejaculatory function after AR that was seen in our series. Barbagli et al. We hypothesize that the higher rate of ejaculatory dysfunction associated with AR is because of the more extensive detachment of the bulbospongiosus muscle in AR needed for a full mobilization of the bulbar urethra.

This detachment can indeed interfere with ejaculatory function. Timing of questioning might again be important: recovery of postoperative ejaculatory dysfunction can be expected once the bulbospongiosus muscle has recovered from the surgical trauma. This cannot be expected after 6 weeks but can be expected after 6 months. Another explanation is that ejaculatory and orgasmic dysfunction is related to ED, which was also more frequent after AR.

In this series, postoperative changes in genital sensitivity were present in approximately 2 out of 3 and 1 out of 2 patients after, respectively, 6 weeks and 6 months. Changes in genital sensitivity were not significantly different among subgroups. This is in line with our findings, but substantially higher than the However, this was a retrospective series with a possible risk of underreporting.

In the same series [ 19 ], only one patient 1. Postoperative changes in genital sensitivity might be explained by postoperative haematoma formation, oedema, and inflammation. Furthermore, in the majority of patients treated by FGU, a preputial skin graft was used.

These factors might certainly explain the high rate of early 6 weeks changes in genital sensitivity. However, even after 6 months, changes in genital sensitivity were still frequently reported, and this occurs also in patients treated with oral mucosa. This might be explained by damage to some sensory branches of the perineal nerves that supply the ventral surface of the penis [ 24 ].

By transecting the entire corpus spongiosum, one would expect a higher rate of impaired glans tumescence after AR. This was not observed in this series. However, interpretation of the results is hampered by the small number of patients.

This series again underlines the concern of possible alterations in sexual functioning and genital sensitivity after bulbar urethroplasty. Therefore it should be part of the evaluation of patients treated by urethroplasty.

Jackson et al. However, this PROM lacks a section on sexual functioning. Furthermore, it would be interesting to evaluate whether modifications in urethroplasty techniques such as muscle- and nerve-sparing bulbar urethroplasty [ 28 ] and vessel-sparing anastomotic repair [ 29 ] will be associated with less sexual dysfunction.

Important limitations of the present series are the small sample size and the missing data in the postoperative questionnaires. Bilateral tract damage must occur for clinically evident disease as the muscles are bilaterally innervated. There may also be neurological deficits in the limb - eg, increased tone, enhanced reflexes and weakness.

New developments in technology have led to the use of neurophysiological investigations to assess various aspects of speech dysfunction. Other tests will depend on the suspected underlying cause but will involve routine blood tests, imaging of the brain and brainstem either CT scan or MRI and electromyography.

Basiri K, Ansari B, Okhovat AA ; Life-threatening misdiagnosis of bulbar onset myasthenia gravis as a motor neuron disease: How much can one rely on exaggerated deep tendon reflexes. Adv Biomed Res.

Thiel A, Hartmann A, Rubi-Fessen I, et al ; Effects of noninvasive brain stimulation on language networks and recovery in early poststroke aphasia. Epub Jun Curr Opin Neurol. Neurology, ophthalmology and psychiatry ; Royal College of Physicians, J Clin Diagn Res. Epub Jan 1.

Murdoch BE ; Physiological investigation of dysarthria: recent advances. Int J Speech Lang Pathol. There seem to be no postings about TGA, so I thought I'd start one up as it is quite a bewildering experience.

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Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions. By using this site you agree to our use of cookies. You can opt out at any time or find out more by reading our cookie policy. This article is for Medical Professionals. In this article The components of normal speech Disorders of articulation Bulbar palsy Pseudobulbar palsy Investigations Management Complications Prognosis.

Synonyms: 'bulbar palsy' - lower motor neurone dysarthria, neuromuscular dysarthria, atrophic bulbar paralysis; 'pseudobulbar palsy' - upper motor neurone dysarthria, spastic dysarthria The components of normal speech Speaking is a voluntary task which is taken for granted but is a highly specialised activity.

In order to speak, the following parts of the oral cavity need to be used: Larynx Pharynx Palate Tongue Lips Along with this, controlled expiration is required, so that air can be released at the appropriate speed and in appropriate amounts. Larynx - produces vowels and some consonants. Lips - produce m , b and p. Lingula - l and t. Throat and soft palate guttural - nk and ng.

N ormal pressure hydrocephalus NPH is a syndrome characterized by gait disturbance, cognitive impairment, and urinary incontinence, as well as enlargement of the ventricles, which results from disturbance of CSF circulation in a setting of normal CSF pressure. Secondary NPH occurs after trauma, subarachnoid hemorrhage, meningitis, or intracranial surgery, and the idiopathic form is characterized by no known causative disorders.

The pathogenesis of NPH remains uncertain, although several hypotheses have been proposed. Suggested mechanisms responsible for the associated clinical symptoms include reduction in blood flow and metabolism, and altered neuronal conduction due to stretching of periventricular white matter PVWM.

Many other symptoms have been reported, including subsequent apathy, anxiety, depression, 34 , 39 , 43 impaired wakefulness, 7 , 24 and sexual dysfunction, 31 but on our review of the literature, no previous studies have investigated and reported on bulbar dysfunction in NPH. We observed that several patients with a history of frequent choking had been admitted to the intensive care unit because of aspiration pneumonia before a diagnosis of NPH was made.

Soon after shunt placement surgery, these patients had no further episodes of aspiration or choking. Moreover, these patients experienced hoarseness or hypophonia, which is usually concomitant with some degree of aspiration. The cessation or reduction in severity of aspiration also occurs after the CSF tap test.

These symptoms may be explained by a stretching of PVWM. An enlarged ventricle can affect corticospinal integrity, thereby causing gait disturbance in a patient with NPH.

The primary objective of this study was to compare preoperative and postoperative prevalence of bulbar dysfunction in patients with NPH. Secondary objectives included assessing the results of surgery for swallowing, speech, gait, cognition, and urination, and evaluating the correlation between bulbar dysfunction and triad symptoms.

Candidates for our study were patients with probable NPH. The following inclusion and exclusion criteria were adopted. The inclusion criteria all required were as follows: 1 patients with more than 1 of the following symptoms: gait disturbance, cognitive impairment, and urinary incontinence; 2 patients with clinical symptoms that could not be completely explained by other diseases; 3 patients with ventricular dilation documented by CT or MRI; and 4 patients with CSF pressure lower than 20 cm H 2 O with normal CSF cell count.

The exclusion criteria at least 1 required were: 1 patients with diseases or medical conditions of the head and neck region that could cause swallowing and speech problems e. Patients who met all of the above inclusion criteria were enrolled.

Enrolled participants then underwent shunt placement surgery with a ventriculoperitoneal shunt VPS or lumboperitoneal shunt LPS , depending upon surgeon and patient preference. Enrolled participants were evaluated before shunting and at 1, 3, and 6 months after surgery. The initial pressure for the shunt system was set after surgery.

Valve pressure was readjusted at postoperative intervals, as required. Shunt function was assessed regularly, especially when there was no improvement in clinical symptoms. The outcome measurements included: the number of steps and time seconds needed to walk 10 m at free speed; the Thai Mental State Examination TMSE ; 48 and an ordinal urinary incontinence scale, 8 in which the level of incontinence ranged from 1 to 6, with a higher score indicating a more incontinent condition. Bulbar dysfunction was categorized into swallowing problems and speech problems.

A swallowing problem was evaluated using the Swallowing Problem Questionnaire SPQ and a speech problem was evaluated using an articulation test, the volume and frequency of the voice, and resonance. Designed by Manochiopinig et al. The maximum score is 16, with a score of 0 indicating normal swallowing function. The patient or a relative was interviewed by a physician to facilitate the completion of the SPQ.

All patients were evaluated by a professional speech-language pathologist. The assessment consisted of 3 component parts.

Articulation Test. Patients were tested using the Thai Articulation Test TAT , 26 , 27 , which consists of all Thai phonemes, including 21 initial consonants, 8 final consonants, 12 clusters, 24 vowels, and 5 tones in the Thai language. Patients pronounce a list of words aloud until the test is completed and articulation is determined to be normal or abnormal. Volume and Frequency of Voice. Using normal-conversation voice volume, patients count from 1 to 10 into a microphone that is connected to a computer.

The software then computes and analyzes voice volume dB and voice frequency Hz. The distance between the patient's mouth and the microphone was 6 inches. Patients performed this exercise 2 times, with the average of the 2 times recorded as the test result. Resonance is the speech quality that results from sound vibrations in the pharynx, oral cavity, and nasal cavity. Normal resonance is highly dependent on normal velopharyngeal structures and function.

Velopharyngeal structures include the velum, lateral pharyngeal walls, and posterior pharyngeal wall. Hypernasality is a resonance disorder that results from velopharyngeal inadequacy VPI.

Specifically, in patients with hypernasality, oral sounds inappropriately resonate into the nasal cavity due to inadequate closure of the velopharyngeal valve. The RST is composed of 3 short speech sentences and 2 examinations of velopharyngeal function. Each of the 5 items is rated as being either normal successful or abnormal unsuccessful.

The maximum score is 5, with a score of 0 score indicating normal velopharyngeal function. A nasometer —3, Kay Elemetrics Corp. This device consists of a headset that has directional microphones for the nose and mouth. These microphones are separated by a baffle that rests against the upper lip Fig.

The microphones pick up acoustic energy from the nasal and oral cavities. The ratio of nasal to total nasal plus oral acoustic energy is then calculated. Individuals with VPI were assumed as having hypernasality, which manifested as high nasalance scores.

Patients were asked to read 3 standard passages from the Thai Nasality Test. The second passage is an oral passage that is devoid of nasal consonants. The third passage is an oronasal passage that comprises a mix of oral and nasal consonants used in everyday conversation. Nasalance scores were compared with normative data of Thai subjects. In the present study, only the oronasal passage was used to determine whether resonance was hypernasality or not.

Comparisons between before and after shunt placement were performed using the Wilcoxon signed ranks test or McNemar's test. Correlations were analyzed using Spearman's rank correlation coefficient r s , Pearson's correlation coefficient r , or point-biserial correlation coefficient r p.

There were 35 males and 18 females, with a mean age of Of 53 patients who underwent shunt surgery, 3 patients were lost to follow-up at the 6-month time point for the following reasons: 1 patient died due to upper airway obstruction, 1 patient developed pneumonia with sepsis, and 1 patient suffered a traumatic intracranial hematoma ICH; Fig.

Patient demographic data are shown in Table 3. Patient clinical data are given in Table 4. Fifty-two patients improved in at least 1 of 3 triad symptoms. One patient was a nonresponder, having failed to improve in any of the 3 triad symptoms.

The nonresponding patient also developed acute kidney injury at 1 month after shunt placement. Fifty patients received swallowing assessment at 6 months postoperatively. Three patients were lost to followup for the reasons described immediately above. The maximum SPQ score in our study population was 10 points out of a possible maximum of 16 points Fig. Distribution of change in swallowing problem severity score from preoperatively to 6 months postoperatively.

The numbers in the first row and first column represent the number of symptoms SPQ score. Clear cells indicate no change, light gray cells indicate improvement, and dark gray cells indicate deterioration. Forty-nine patients were given a speech assessment at 6 months after shunt placement. Three patients were lost to follow-up for the reasons mentioned above, 1 of whom developed an ICH due to coagulopathy.

The articulation of 28 patients remained abnormal postoperatively Table 3. No correlation was identified between loudness and triad symptoms. Of the 37 patients with preoperatively abnormal RST scores, 11 became zero RST scores, 10 had a decreased RST score, 13 had no change, and 3 experienced deterioration in their condition at 6 months after shunt placement.

Distribution of change in RST score from preoperatively to 6 months postoperatively. The numbers in the first row and first column represent the RST score. Mean nasalance scores are shown in Table 4. No significant difference was observed between preoperative and postoperative mean nasalance scores. In , Adams remarked that his patients with NPH became quiet and had slow speech that progressively developed into whispering or no ability to speak at all. Of 53 probable patients with NPH, only 1 was identified as a nonresponder after shunt placement surgery.

After shunt placement, significant improvement was observed in swallowing function, speech characteristic resonation , and speech quality increasing volume. Statistically significant correlations were found between swallowing problem and gait disturbance, articulation disorder and gait disturbance, and speech problem and cognitive impairment.

Interestingly, no previous investigation has reported on bulbar dysfunction in NPH, even though dysphagia is a very common feature in neurological disorders. We also found bulbar dysfunction to be significantly correlated with TMSE score. One patient was lost to follow-up due to pneumonia with sepsis. The diseases of the patients before NPH consisted of 7 with supratentorial tumor, 3 with supratentorial ICH, 2 with subarachnoid hemorrhage, 1 with traumatic epidural hematoma, and 1 with previous craniectomy.

None of the patients had bulbar symptoms when they had these diseases before NPH and they experienced a good recovery after treatment. As such, the comorbid disease of secondary NPH in the present study should not have caused the bulbar palsy.

The patients with neurological lesions that cause bulbar palsy were not enrolled because of the exclusion criteria. Based on our clinical experience, we observed that severity of bulbar symptoms correlated well with late or worsening NPH triad symptoms, which were usually found in cases with severe apathy or sleepiness.

Inadequate drainage after CSF shunting also correlated with worsening of bulbar symptoms. As such, they can be used as landmark symptoms for diagnosis and treatment monitoring.

There are 2 possible pathoanatomical causes of bulbar dysfunction in NPH. The first cause involves PVWM damage. Levine et al.

Bulbar sexual dysfunction