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Aims: A proof of principle study of a novel wearable device to control neurogenic detrusor over-activity in eight male spinal cord injured subjects using conditional neuromodulation. Methods: Transrectal stimulation was delivered through the device in response to simultaneously recorded external anal sphincter (EAS) contraction as a marker for neurogenic detrusor overactivity (NDO). The effect of conditional neuromodulation on bladder capacity and maximum detrusor pressure was investigated in addition to reliability of dyssynergic sphincter contraction as a marker for NDO. Results: Conditional neuromodulation through the novel device showed a statistically significant increase in bladder capacity and reduction in maximum detrusor pressure in six male subjects with spinal cord injury (SCI). EAS activity was a reliable surrogate for detection of NDO. Conclusions: It has been shown for the first time that conditional neuromodulation can be delivered and triggered via a single biocompatible device placed in the anal canal. The pudendal nerves lying in Alcock's canal were stimulated through the wall of the anal canal, and the dyssynergic activity of the EAS was used to detect NDO and trigger neuromodulation giving significant increases in bladder capacity and reduction in detrusor pressure in six male subjects with SCI. K E Y W O R D S neurogenic detrusor over-activity, neuromodulation, spinal cord injuryThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.© 2017 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc.Abbreviations: AD, autonomic dysreflexia; CN, conditional neuromodulation; DP, detrusor pressure; DSD, detrusor sphincter dyssynergia; EAS, external anal sphincter; EAS EMG, external anal sphincter electromyogram; EMGthresh.min, value of EAS EMG at which CN would be triggered; EUS, external urethral sphincter; iSCI, incomplete spinal cord injury; MCC, maximum cystometric capacity; MDP, maximum detrusor pressure; NDO, neurogenic detrusor overactivity; PPV, positive predictive indicator; SCI, spinal cord injury; T NDO , time at which detrusor pressure exceeded 15 cmH 2 O.John Heesakkers led the peer-review process as the Associate Editor responsible for the paper.Neurourology and Urodynamics. 2018;37:385-393.wileyonlinelibrary.com/journal/nau | 385

Cortical TMS was effective in facilitating the PAR in some iSCI subjects. The presence of cortical facilitation of the PAR was not related to the degree of urinary continence.

Study design: Two case studies. Objectives: To determine whether 6 weeks of regular pelvic floor muscle training (PFMT) can improve the strength and endurance of voluntary contractions in incomplete spinal cord injury and reduce neurogenic detrusor over-activity (NDO) and incontinence. Setting: The London Spinal Cord Injury Centre, Stanmore, London, UK. Methods: A 6-week programme of PFMT was conducted in two male subjects with stable supra-sacral motor incomplete (AIS C and D) spinal cord injuries. Clinical evaluations before and after training comprised measures of strength and endurance of voluntary pelvic floor contractions both objectively by anal canal-pressure measurements and subjectively using the modified Oxford grading system. NDO was determined by standard urodynamic tests of bladder function and incontinence measured by the International Consultation on Incontinence Questionnaire-Urology. Results: Both subjects improved the strength and endurance of their pelvic floor muscle contractions by over 100% at the end of training. After training, Subject 1 (AIS D) was able to reduce bladder pressure during over-activity almost completely by voluntarily contracting the pelvic floor muscles. Subject 2 (AIS C) achieved a lesser reduction overall after training. Continence improved only in subject 1. Conclusion: These case studies provide evidence that a 6-week programme of PFMT may have a beneficial effect on promoting voluntary control of NDO and reduce incontinence in selected cases with a motor incomplete spinal cord lesion. INTRODUCTIONIncontinence remains a priority problem for many people with spinal cord injury 1 despite various current treatments including conservative therapies. 2 Control of the bladder, sphincter and pelvic floor muscles (PFM) relies on the integrity of bulbo-spinal, cortico-spinal and lumbo-sacral reflex pathways. Following a motor incomplete spinal cord injury (iSCI), voluntary control of the PFM including the striated sphincters significantly weakens, neurogenic detrusor over-activity (NDO), detrusor sphincter dyssynergia and incontinence emerge reducing quality of life. Although PFM training (PFMT) has been shown to be effective in non-SCI patients with lower urinary tract symptoms, for example, by reducing stress incontinence and suppressing bladder over-activity, 3 it appears not to have been tested as a potential therapy in iSCI. Therefore the aim of these two case studies was to determine whether 6 weeks of regular PFMT could improve the strength and endurance of voluntary PFM contractions in iSCI so as to suppress NDO and reduce incontinence. A positive outcome may then justify a pilot study with a larger cohort of iSCI subjects presenting with preserved sensorimotor pathways of the sphincters and PFMs. MATERIALS AND METHODS ParticipantsA 6-week programme of regular PFMT with clinical assessments before and after was conducted in two male subjects presenting with chronic-stable iSCI, NDO and incontinence.Local research ethics committee approval was obtained (REC Reference ...

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