Introduction
Storage of urine following suprasacral SCI is often interrupted by uninhibited contraction of the detrusor muscle, neurogenic detrusor overactivity (NDO), often at low volumes and socially inconvenient times. NDO can cause high detrusor pressures that may lead to ureteral reflux or urinary incontinence.

Transcutaneous Dorsal Genital Nerve Stimulation (DGNS) is a non-invasive neuromodulation technique that can suppress NDO when applied continuously, intermittently or conditionally at the onset of a detrusor contraction. It has not yet been translated into clinical use and questions remain over how best to apply stimulation, whom it is suitable for and whether individual’s residual sensation is a reliable trigger for conditional neuromodulation during natural filling of the bladder.

Methods
Ambulatory Urodynamic Monitoring (AUM) was used to record Average Peak Detrusor Pressure (APDP), Maximum Detrusor Pressure (MDP) and number of rises in detrusor pressure over natural filling cycles. Maximum Cystometric Capacity (MCC) was recorded by emptying the bladder when either strong urge or leakage occurred. AUM was used to record control values, before using DGNS, followed by whilst using DGNS conditionally (n=4) or continuously (n=1) and again using intermittent DGNS (n=1). AUM was repeated following a week of using DGNS when desired at home.

DGNS was applied using surface electrodes over the penis or clitoris, using an Odstock stimulator controlled wirelessly from a custom smartphone application. Participants with residual bladder sensation triggered stimulation on-demand and those without trialled continuous and intermittent (5 s on - 5 s off) stimulation. Paired results from each session were tested using a Wilcoxon signed-rank test.

Results
Five people participated in the study, each with suprasacral SCI, NDO and on antimuscarinic medication (AM) (age 52±11 years, ASIA A-D, C5-T10, 12±5 years from injury).

DGNS was able to suppress NDO during natural filling in all participants. The number of rises in detrusor pressure, before leakage or urgency requiring emptying, increased from 1.5±1.4 during control to 4.3±1.7 when using DGNS, p=0.0234. MCC, bladder capacity, was increased from 244±59 to 346±61 ml (p = 0.0078), by 46±25%, using DGNS. MDP was reduced from 58±18 cmH₂O in baseline to 47±18 cmH₂O (p=0.0156), by 17±13%, with DGNS. APDP was reduced from a baseline of 56±16 cmH₂O to 31±18 cmH₂O (p=0.0156), by 50±19%, with DGNS.

Intermittent and continuous stimulation both increased MCC and decreased APDP and MDP, though incontinence was not prevented due to the lack of sensory or artificial feedback available to the participant. On-demand DGNS was able to acutely suppress rises in detrusor pressure, suggesting it is a safe and feasible method of triggering neuromodulation.

No changes in outcomes were found within participants following one week of using DGNS at home.

Conclusions
Non-invasive DGNS is able to reduce average and peak detrusor pressures and increase bladder capacity when applied on-demand, continuously or intermittently in conjunction with AM regimes, from a baseline taken with participants on AM only. This represents a wearable bladder management technique that may be used alongside AM to better meet urological management goals.

Introduction
Although researchers reported body weight supported treadmill training (BWSTT) using robot suit Hybrid Assistive Limb (HAL) improves gait performance in chronic spinal cord injury (SCI) patients, there are no reports which include the subjects with no walking ability. The aim of this study was to clarify the effectiveness for BWSTT using HAL in chronic SCI patients with no walking ability at baseline.

Methods
Six chronic SCI patients (men; 43.3 ± 14.7 years old; injury level: C6-Th5; post-injury month: 63.5 ± 27.9) with no walking ability were included in this study. Four subjects were categorized as the American Spinal Injury Association Impairment Scale (AIS) grade B and two as grade C. Participants underwent 40-sessions of BWSTT with HAL (60 min per session, 2–5 sessions per week). Walking index for SCI scale II (WISCI-II), Berg Balance Scale (BBS), Trunk strength (Tr-strength) to maintain sitting posture for four directions (anterior, posterior, left and right), Barthel Index (BI), Functional Independence Measure (FIM) were assessed at pre-training and post-40 training sessions. The change in each outcome measure from pre- to post-training was assessed using a Wilcoxon signed-rank test. Differences were considered statistically significant at p < 0.05.

Results
Tr-strength in sagittal plane (anterior and posterior) of four patients that we could measure tended to improve from pre- to post-intervention (0.3 ± 0.4 [kgf] to 3.0 ± 1.4 [kgf] and 1.4 ± 1.6 [kgf] to 7.6 ± 4.2 [kgf]). Average value in frontal tr-strength (right and left) also showed improvement (1.3 ± 1.8 to 4.4 ± 2.1). In balance function, all subjects showed significant improvement in BBS score from pre- to post-intervention (3.7 ±1.6 to 5.0 ± 2.3, p＜0.05). With regards to the waking function, two subjects categorized as AIS grade C showed improvement in WISCI-II score from pre- to post-intervention (0 to 1, which mean they became able to stand and walk several meters with the support by two persons). However, the remaining four AIS grade B subjects showed no improvement in WISCI-II. There were no changes in BI and FIM for all subjects from pre- to post-intervention (46.7 ± 9.0 to 46.7 ± 9.0 and 40.0 ± 11.7 to 40.0 ± 11.7, respectively)

Conclusions
Our results suggest BWSTT with HAL is effective to improve balance function of trunk in chronic SCI patients with no walking ability. Also, improvement of walking function shown in subjects with no walking ability is an encouraging result for chronic SCI patients. Further investigation with increasing numbers of subjects is needed.

Introduction: People with spinal cord injury (SCI) are known to have neurogenic bowels, usually characterized by constipation and bowel incontinence which significantly affect quality of life. This may be accompanied by considerable abdominal pain, bloating, epigastric burning, and early satiety. Existing gastrointestinal (GI) tests require substantial burden to the patient since these are difficult to perform, require several visits and do not provide a comprehensive evaluation of function and transit. The Wireless Motility Capsule (WMC), an ingestible capsule uses sensory technology to measure segmental GI transit times in a single procedure and characterization of patterns of dysmotility in the upper and lower GI tract.

Objective/s: The primary objective of study is to examine gastric emptying times (GET)s in persons with SCI with the WMC and to define the relationship between GET and colon transit time (CTT). The study will examine the relationships between upper and lower GI motility, pelvic floor and anorectal function (evaluated with the anal rectal manometry- ARM and balloon expulsion test - BET). The study will examine relationships of these findings with SCI level and completeness.

Methods: Eligible subjects with chronic SCI (>1 year) above T12 (AIS A-E) were recruited, consented and evaluated with the WMC and ARM/BET. Subjects undergo the WMC protocol prior to, during (7 days) and after receiving the WMC. ARM is performed on the day WMC is provided.

Results: A total of 14 subjects completed the study. Of these 14 subjects, 11 have had tetraplegia (1 AIS A, 2 AIS B, 2 AIS C, 5 AIS D, and 1 AIS E) and 3 have had paraplegia (2 AIS A and 1 AIS D). Overall, WMC showed delayed GET= 5, small bowel transit time (SBT)=3, CTT =7, whole gut transit time (WGTT) =7. GET was delayed in 3/3 AIS A, 0/2 AIS B, 2/2 AIS C, 3/6 AIS D, 0/1 AIS E. SBT was delayed in 1/3 AIS A, 0/2 AIS B, 0/2 AIS C, 2/6 AIS D, 0/1 AIS E.
CTT was delayed in 2/3 AIS A, 0/2 AIS B, 0/2 AIS C, 4/6 AIS D and 1/1 AIS E. WGT was delayed in 2/3 AIS A, 0/2 AIS B, 1/2 AIS C, 4/6 AIS D, 0/1 AIS E. On ARM, sphincter squeeze results showed poor = 6, adequate =1, good =1, excellent = 2 (unk4); response to cough normal = 7, suboptimal =4 (unk3); simulated defecation was normal=2, with dyssynergia type 1= 6 and type 4= 3(unk3). The balloon expulsion test (BET) was abnormal =8 and normal= 4 (unk2). Due to the current small sample size, there were no statistically significant associations found between results of upper and lower GI findings and between AIS level or completeness of injury.

Conclusion: There are varying but meaningful descriptive results of dysfunction in segmental GI times and WGTTs assessed by the WMC and pelvic floor and anorectal dysfunction evaluated by the ARM in subjects with SCI related to level and completeness of injury. Increased sample size is necessary to determine significant associations.

Introduction
SCI patients have a significant higher rate of UTI along the course of pregnancy. The risk is higher by 37% when compared to pre-injury pregnancy.
Methods
A thorough literature search was conducted to look for the available data in main databases (MEDLINE, EMBASE and CINHAL) using appropriate search terms. The identified data was reviewed.
Results
American Congress of Obstetricians and Gynaecologists recommends frequent monitoring for UTI and suggests that chronic antibiotic prophylaxis may be appropriate. Sterling et al., 2013, reported that the practice at their centre is to test for UTI during each trimester and to provide antibiotic prophylaxis against recurrent infection.
In a small study, Salomon et al. 2009, investigated prophylactic antibiotic treatment for UTI in pregnant SCI individuals with significant reduction of infection and the uncomplicated term foetus. However, to date there is no definite recommendation on usage of antibiotic except when symptomatic UTI is diagnosed (Mustafah et al. 2017).
Liepvre et al., 2017, reported that a weekly oral cyclic antibiotic (WOCA) was prescribed in 75% of pregnancies in their study population. They reported a lower UTI rate (32%) compared with that in other studies (45 to 100%), but the pyelonephritis rate was still high (30%). There were two different contexts to explain these cases of pyelonephritis (all had overactive detrusor muscle and were using a Clean Intermittent Catheterisation): half happened in patients with well-managed neurological bladder that became high risk, especially with botulinum toxin discontinuation for pregnancy, or change in the anticholinergic drug regime. The other pyelonephritis cases were probably favoured by an overactive bladder that was poorly treated due to patient’s poor compliance to treatment or follow up (Le Liepvre et al., 2017).
Few data is available on botulinum toxin use during pregnancy and breast feeding. Its use is contraindicated during these periods, and for safety a six-month delay has been proposed between last injection and beginning of pregnancy (Le Liepvre et al. 2017).
Women with SCI were also found to have higher rate of premature labour and delivery by 8.6%, and higher rate of low birth-weight baby by 9.1%, which was found to be inter-related and associated with higher incidence of UTI (Morton et al. 2013). In Le Liepvre et al. study (2017), the UTIs explain in large part the 12% prematurity, which remains low compared with that in other studies (13- 21%) and without neonatal complications except for the twin pregnancy.
With advancing gestation, some women may need to change to an indwelling catheter due to limited mobility and incontinence (Cochrane review 2014). One-fourth of the women reported the need to change their usual bladder management method during pregnancy and 27-70% had to increase their number of intermittent catheterisations per day (Jackson & Wadley 1999 and Galusca et al. 2015).
Conclusion
Pregnant women with SCI require specific urological care. However, evidence on urological complications in pregnant women with SCIs is scarce. Well-designed studies are needed to look at the incidence, severity and management of urological complications in this group of patients.

INTRODUCTION: Bowel transit time (BTT) tests are used in people with spinal cord injury (SCI) to assess gastrointestinal function. Radio-opaque markers, SMART pills and Wireless Motility Capsules are commonly used. They are expensive, involve radiation or cannot be used in all patients. We considered sweetcorn as a safe and cost-effective alternative. Sweetcorn kernels are surrounded by cellulose husks which cannot be broken down and appear in stool unchanged.
AIM: The aim of the study is to explore whether sweetcorn can be used as a marker for BTT in general population with a view to assessing the feasibility of its use in people with SCI.
METHODS: Seven people without SCI were recruited, using a convenience sample. Male and female participants from 16 to 80 years of age were included. People with gastrointestinal conditions, sensitivity to sweetcorn and those taking medications that may have an impact on bowel transit time were excluded. They were asked to complete bowel diaries for 2 weeks. At the end of week one, they were asked to ingest 100g of sweetcorn and look for the cellulose husk in their stool. An amount of 100gm was chosen after confirming that it will not affect the BTT, from a literature search. Participants were provided with two weeks of bowel diary. In the first week, they recorded their food and drink intake and the presence or absence of cellulose husks. At the end of the first week, they ingested 100 grams of sweetcorn and continued to keep their bowel diary for another week. The primary outcome measure was the presence or absence of cellulose husks after ingesting the sweetcorn. BTT was calculated by measuring the time between eating the sweetcorn and the time when cellulose husks were found in the stool.
RESULTS: A bowel Diary was used to record food and fluid intake, time of defecation and the presence or absence of cellulose husks of the sweetcorn. The data were analysed using Excel software and descriptive statistics. 7 subjects, (4 male, 3 female). 5 detected cellulose husk in their faeces. Sweetcorn was 71.5% reliable as a BTT marker. BTT is expressed as mean +/- SD 30.9 +/- 18.8. Range of transit times was from 12.6 to 61.1 hours. None of the participants had a concern with eating sweetcorn.
DISCUSSION: Two participants did not identify the sweetcorn in their stool because of inadequate visual inspection. This will not be an issue in people whose bowels are managed by manual evacuation with an opportunity to inspect adequately.
CONCLUSION: Sweetcorn is a potential marker which is easily available, safe and cost-effective to assess BTT in people with SCI especially in those who manage their bowels by manual evacuation. A study with a bigger sample size in people with SCI is required to validate our findings and its use in clinical practice. Further research is needed to determine the mass of sweetcorn required for easy visibility of kernels, which does not affect the gastrointestinal transit time.

Introduction
Neurogenic detrusor overactivity (NDO) is characterized by reduced bladder capacity and elevated detrusor pressure during the storage phase. Antimuscarinic medication or botulinum toxin injections into the detrusor are the main treatment strategies for NDO. However, antimuscarinic treatment is frequently abandoned due to side effects or lack of efficacy, and the disadvantage of botulinum toxin injections is the need for repeated injections. Mirabegron, a β-3-adrenoceptor-agonist, is a new treatment option for NDO, but data in individuals with spinal cord injury are lacking. We have therefore investigated the efficacy and side effects of mirabegron in the treatment of NDO in individuals with chronic spinal cord injury (SCI).
Methods
The patient database of a tertiary urologic referral center was screened for patients with chronic (>12 months) NDO due to SCI who were taking the β-3-adrenoceptor-agonist mirabegron (Betmiga). Patient characteristics, data regarding bladder management, urinary incontinence and medication affecting the bladder as well as urodynamic parameters were collected. The changes in urinary incontinence and the urodynamic parameters under mirabegron treatment over time (pre-mirabegron, 3 and 10 month follow-up) were investigated using Cochran’s Q test and non-parametric analysis of variance. Data are presented as median and quartiles (Q25 / Q75).
Results
The data of 63 individuals with a median age of 48 (range 20-84) years and a median NDO duration of 8.9 (range 1-53) years were analyzed. A median 3.0 months (range 1-53 months) and 7.3 months (range 1-26 months) had elapsed from the mirabegron treatment initiation to the first follow-up evaluation and from the first to the second follow-up evaluation, respectively. The mirabegron treatment significantly (p≤0.04) reduced maximum detrusor pressure during the storage phase from 35cmH2O (23 / 50cmH2O) to 26cmH2O (15 / 40cmH2O). The bladder capacity and detrusor compliance increased significantly (p≤0.005) by 33.3% and 50%, respectively. Furthermore, the number of individuals suffering from urinary incontinence decreased significantly (p=0.002) from 62.3% to 33.9% and 36.4% at the first and second follow-up investigation, respectively. A total of 65.1% were taking mirabegron additionally to an already established NDO treatment (antimuscarinics, botulinum toxin injections). Mirabegron treatment was stopped in five individuals due to insufficient efficacy. Five individuals complained of side effects such as tachycardia, dry skin, head and stomach ache, but mirabegron treatment was continued.
Conclusions
Mirabegron treatment improved urodynamic and clinical parameters in individuals with NDO due to SCI. Mirabegron seems to be effective and well tolerated in the treatment of NDO.