Journal of the Neurological Sciences, 1976, 28 : 1-15

~ Elsevier Scientific Publishing Company, Amsterdam - Printed in The Netherlands

BULBOCAVERNOSUS REFLEX IN NORMAL MEN AND IN PATIENTS WITH NEUROGENIC BLADDER AND/OR IMPOTENCE

C U M H U R ERTEKIN* and FATIN REEL**

Department oJ" Clinical Neurology, Medical School Hospital, Aegean University, Bornova, lzmir (Turkey)
(Received 11 August, 1975)

SUMMARY

The bulbocavernosus reflex was investigated electrophysiologically in 14 normal adult male subjects and in 80 patients with neurogenic bladders and/or impotence due to various neurological causes as well as in patients with functional impotence. The glans penis was stimulated superficially by single electrical shocks and the reflex responses were recorded from the bulbocavernosus (BC) and the striated anal sphincter muscles by means of concentric needle E M G electrodes. In all normal subjects, the BC reflex was recorded from the BC muscle as a stable and constant response having a mean latency of 36.1 msec. A response from the external anal sphincter was obtained in only 21 ~o of the subjects investigated. In 13 patients with cauda equina lesions, the BC reflex was either absent or was present with a prolonged latency. Twenty-two patients with polyneuropathy of various causes were also investigated; in these patients the latency of the BC reflex was significantly greater than in the normal controls, but the most abnormal results were obtained in cases of alcoholic polyneuropathy. In the 19 cases of spinal cord disease with spasticity the BC reflex response was very intense, often with after discharges but latency values were within normal limits. In the 16 cases with functional impotence, the BC reflexes were basically normal; but in 3 cases, the threshold of the reflex was significantly raised, and in 1 case a prolonged latency was observed. The value and the practical application of the BC reflex in the differential diagnosis of bladder dysfunction and of impotence was stressed.

* Associate Professor in clinical neurology. ** Resident in neurology.

INTRODUCTION

The bulbocavernosus reflex is well known in urological literature and is often used to assess the differential diagnosis of bladder dysfunction (Lapides and Bobbitt 1956; Bors and Blinn 1957, 1959; Pierce, Roberge and Newmann 1960). The urologist evokes the reflex in such a way that the glans penis is compressed between the thumb and index finger while reflex contraction of the bulbocavernosus (BC) and striated anal sphincter muscles is felt either by palpating the skin behind the scrotum at the midline for the BC muscle or more often by placing the index finger in the distal portion of the anal canal for the external anal sphincter muscle. The absence of the BC reflex is considered to be an indication ofa neurogenic cause for bladder dysfunction. The neurologist, on the other hand, does not generally use the BC reflex in routine examination although the presence of the reflex seems to be important as it could indicate the neural integrity of sacral spinal segments 2, 3 and 4, and of their afferent and efferent connections in the urogenital region. The BC reflex has been investigated previously by electromyographic (EMG) methods but the stimulation and recording techniques described were insensitive and crude (Ratner, Gerlaugh, Murphy and Erdman 1958; Bors and Blinn 1959; Pierce et al. 1960). None of these authors showed any obvious superiority of electrophysiological methods over clinical examination of the BC reflex. In 1967, Rushworth stressed the diagnostic value of the BC reflex and reported briefly an electrophysiological method evoking the reflex by electrical shocks applied to the glans penis. The nociceptive reflex recorded from the BC muscle was found to be very stable and did not show habituation; its latency was about 35-40 msec in normal male subjects. Using a similar technique to that reported by Rushworth (1967) we investigated the BC reflex electrophysiologically in 14 normal adult men and in 80 patients with neurogenic bladder and/or sexual impotence of various neurological causes as well as in patients with functional impotence. It wiil be shown that the electrophysiotogical method of evoking the BC reflex is useful in evaluating neurogenic bladder disorders as well as neurogenic sexual impotence in men.
MATERIAL AND METHODS

Fourteen normal male volunteers who were normopotent and had no systemic disease were investigated. Their ages ranged from 16-56 years with a mean age of 33.5. Eighty patients were also included in the study. The clinical diagnoses in the patients are summarized in Table 1. A diagram of the anatomical basis of the BC reflex and the technique used in this study is illustrated in Fig. 1. The subject was placed in the lithotomy position on an examination table. Stimulation electrodes were of the same type as those used for stimulating distal sensory nerves (DISA 13 K 65). The 2 electrodes were wrapped circumferentially around the glans penis, perpendicular to the long axis of the penis and in some subjects these electrodes were

TABLE 1 NUMBER OF PATIENTS IN DIFFERENT DIAGNOSTIC GROUPS Diagnosis Mean age (years) Age range (years) Number of cases investigated 14 13 22 19 16 10
Total 94

Control subjects Cauda equina lesions (trauma, turnout, herniated disc, etc.) Polyneuropathy (diabetes, alcoholism, etc.) Spinal cord disease (turnouts, myelitis, M.S., A.L.S., etc.) Functional impotence Miscellaneous

33.5 44.2 46.2 41.8 31.8 38.6

16 56 25 63 16-67 26 57 21-53 25-50

ST

Fig. 1. Diagram of the anatomical basis of the bulbocavernosus reflex and the position of the electrodes used for stimulation and recording. ST, stimulation electrodes; R1 and R2, sites of the recording electrodes in the bulbocavernosus (BC) and external anal sphincter muscles, respectively. The dotted line denotes the theoretical suprasegmental influence over the interneurons of the sacral spinal cord. also placed a r o u n d the most proximal part of the organ. The proximal s t i m u l a t i o n electrode was always connected to the cathode of the stimulator. The electrodes were supported a n d s u r r o u n d e d by a mass of cotton in order to separate them from the other parts of the genital skin. The electrodes used for recordivg the E M G reflex activity were concentric needle electrodes (DISA 13 K 03) which were inserted into the BC and the external anal sphincter muscles. The BC muscle was easily reached behind the scrotum, near the midline in the perianal region. In order to locate the

BC muscle for electrode insertion, cooperation was requested from the patient either by coughing gently or attempting to erect the penis, or else the glans penis was squeezed slightly by the examiner. Both procedures produced clear-cut motor unit responses in the oscilloscope. In the resting position the BC muscle was completely silent. The external anal sphincter muscle was even easier to locate and when the concentric needle electrode was introduced into the sphincter, abrupt and continuous tonic E M G activity appeared which could be traced on the oscilloscope. In a few subjects, ischiocavernosus, levator ani, and external urethral sphincter muscles were also explored and their reflex activities were recorded. External urethral sphincter muscle was located according to the technique described by Petersen and Stener (1970). A long circular ground electrode was placed around the lumbar region of the subject investigated. The recording electrodes were connected to the input of the electromyograph (DISA 14 A 30) and the stimulation electrodes situated around the glans penis, were connected to the output of the stimulator (DISA Ministim 14 E 10). The glans penis was stimulated with rectangular pulses of 0.1 and/or 0.2 msec duration at intensities beginning from "0" rising up to "500" V in a stepwise manner. The psycho-sensory threshold for sensation on the glans penis was estimated by such a progressive increase in stimulation at a rate of l/sec, in each case with durations of stimulation of 0.1, 0.2 and sometimes 0.5, 1.0 up to 2.0 msec. The reflex threshold from the BC muscle was also determined by the same procedure. Finally, the glans penis was stimulated maximally. In all normal subjects, rectangular pulses with 0.2 msec duration and 400-500 V intensity were sufficient to evoke very stable reflex responses from the BC muscle. In some patients, especially in those with lesions of the cauda equina, it was necessary to use electrical shocks with 0.5 or 1.0 msec duration and 500 V intensity. Even trains of repetitive electrical shocks at 100/sec were tried in a few cases. The maximal electrical stimuli used with all normal control subjects and with the majority of the patients investigated did not evoke any painful sensations in the subjects. The sweep speed used for recording the reflex action potentials on the film was 2.5 and 5.0 msec/mm. Ten to 20 superimposed sweeps, as well as single sweeps were photographed. The reflex conduction time was measured from the beginning of the stimulus artifact to the onset of the first action potential of the reflex response.
RESULTS

Normal subjects
The rectangular electrical shocks with 0.1-0.2 msec duration applied on the glans penis were first perceived at about an intensity range of 80-150 V in all normal subjects. Although the psychosensory threshold of a given subject could vary for different trials, such differences were not significant so that approximate values could be assigned to threshold. When the stimulus strength was increased 2-4 times above the psychosensory threshold a reflex response appeared in the BC muscle. Electrical shocks 1.5-2.5 times stronger than the reflex threshold produced stable and

TABLE 2 S U M M A R Y OF RESULTS F R O M N O R M A L SUBJECTS A N D P A T I E N T G R O U P S

Diagnosis

Number of cases investigated

Mean latency of bulbocavernosus reflex (msec)~

Absence of Percentage reflex responseb showing anal sphincter reflex response

21~ 33~

Normalcontrols Caudaequinalesions

14 13

36.1 i 1.2 4.6 0 (27.5 - 42.5) 65.0 8.2 20.0 6

Polyneuropathy Spinal cord disease Functional impotence

22 19 16

(42.5- 100.0) 47,8 4.9 22.7 0 (30.0 - 140.0) 36.0 1.3 5.8 0 (27.5 47.5) 36.5 1.7 6.7 0

33 62.5% 36~

~ Mean SEM, standard deviation, (range).

h No. o['cases.

constant E M G discharges in the BC muscle. Fig. 2 shows a BC reflex response from a normal control subject. In Table 2 we summarize the results from the normal controls and the patient groups. The mean latency of the reflex was 36.1 msec and ranged from 27.5 to 42.5 msec in 14 normal subjects. The reflex had the shape of either a single motor unit response or a polyphasic response with a few units firing together. In 4 cases, the reflex consisted of double components as is seen in other flexor polysynaptic reflexes. Intense responses or after-discharges were not encountered within the stimulation limits set for normal controls. Stimulation of the glans penis did not constantly evoke a reflex response from the external anal sphincter muscle and only 21 o//o of the cases investigated showed such a reflex response (Fig. 3). If present the reflex became less stable, its threshold being higher than that of the BC muscle with latencies ranging from 35 to 100 msec, in 3 cases. In 3 normal male subjects, the most proximal part of the penis was also stimulated (Fig. 4). Proximal stimulation produced a similar stable response, but with a shorter latency. In these normal subjects and in some patients, the results of stimulation at two different points are listed in Table 3. In spite of the short conduction path presented by the penis, it was possible to calculate the afferent conduction velocity of the BC reflex following distal and proximal stimulation of the penis. Except for the patients in whom peripheral nerves and/or reflex arcs were involved by disease, the conduction velocity was found to be between 10 and 25 m/sec, with an average of 18.9 m/sec for adult male subjects. The other muscles situated in the urogenital diaphragm, were not systematically investigated. But in a few subjects including some of the patients, the striated urethral sphincter muscle seemed to be consistently involved during glans penis stimulation. The reflex threshold in this sphincter was almost the same as in the bulbocavernosus

Fig. 2. Bulbocavernosus reflex recorded from the BC muscle after stimulation of the glans penis in a normal 22-year-old male control subject. Stimulus strength 500 V and 0.1 msec duration. Rate l/sec. Calibration: 200 #V and 50 msec. A downward deflection of the trace is positive in this and all subsequent figures.

Fig. 3. The reflex response from the BC muscle (on the right) and recording from the external anal sphincter (on the left) in a normal 54-year-old male control subject. Upper traces are 10 superimposed sweeps and lower traces single sweep. Stimulus strength on the glans penis i~ 500 V and the duration 0.1 msec. Calibration: 200/tV and 25 msec. Note the absence of the reflex response in the external anal sphincter.

Fig. 4. BC reflex elicited by stimulation of the glans penis (upper trace) and by stimulation of the proximal part of the penis (lower trace) in a normal 54-year-old male, Each trace is 10 superimposed sweeps. Stimulus strength 500 V and duration 0.1 msec for each stimulation site. Calibration: 200 /tV and 25 msec.

TABLE 3 RESULTS OF A F F E R E N T C O N D U C T I O N VELOCITY WITH THE BC REFLEX ALONG THE PENIS D E T E R M I N E D Cases Age (years) 20 54 56 24 23 29 53 21 57 39 50 33 47 55 Diagnosis Conduction velocity (m/sec) 20.0 10.0 11.0 19.0 18.5 12.0 15.0 25.0 19.0 24.0 24.0 2O.O 23.0 25.0 Mean ~ M.K. H.I. S.G. K.A. R.O. H.K. 49 26 50 41 54 55 diabetic neuropathy diabetic neuropathy diabetic neuropathy diabetic neuropathy acromegalic neuropathy polyneuropathy (aetiology unknown) Mean n Y.V. I.K. 44 50 neuralgic amyotrophy cauda equina syndrome 18.9::i 1.3; 5.1 19.0 18.0 14.0 13.0 7.0 8,5 13.2 -A: 2.0;4.8 18.0 8.5

M.(~. H.M. M.A. R.A. H.K. M.E. O.U. K.S. H.O. M.$.t~. H.P. H.O. H.K. V.A.

normal subject normal subject normal subject functional impotence functional impotence functional impotence functional impotence functional impotence spinal tumour (upper thoracic) spastic paraparesis (aetiology unknown) hereditary spastic paraparesis transverse myelitis spastic paraparesis (aetiology unknown) epilepsia

Mean 4- SEM ; standard deviation.

Fig. 5. Recordings from the BC muscle (on the left), the external urethral sphincter (in the middle) and the external anal sphincter in a male patient with transverse myelitis. Ten superimposed sweeps. Stimulation of the glans penis, 400 V and 0.1 msec. Calibration: 100 .uV and 25 msec. Note the clearcut reflex response from the external urethral sphincter.

muscle for a given case but with a shorter latency (Fig. 5). The ischiocavernosus muscle showed the same reflex activity as the BC muscle while the levator ani behaved like the external anal sphincter upon glans penis stimulation.

Cauda equina lesions

Thirteen patients with a cauda equina syndrome had the typical neurological picture including sphincter disturbances and impotence. The causes of the syndrome were mostly trauma, tumours and prolapsed discs, which were verified by myelography and/or surgery. The psychosensory threshold was significantly higher than in normal subjects. Four of these patients never felt any sensation even with maximal stimulation of the glans penis. Similarly the threshold of the BC reflex was significantly higher and no reflex response could be obtained in 9 patients under the usual stimulation conditions. In 6 of these 9 cases the BC reflex was completely absent in spite of very intense stimulation including single shock trains of 100/sec frequency. The remaining pa-

Fig. 6. BC reflex from a 36-year-old male patient with traumatic injury of the cauda equina (lower trace) and from a normal 54-year-old male (upper trace). All responses shown are 10 superimposed potentials. Stimulation of the glans penis, 0.1 msec, 500 V (for normal subject) and 0.5 msec, 500 V (for the patient). Calibration mark (the lowest trace) :100/~V (from peak to peak) and 10 msec (in between 2 successive positive peaks). Note the remarkably delayed BC reflex in the patient with the cauda equina syndrome.

10 tients showed a reflex response after such intense single or repetitive stimulation of the glans penis which was normally painful and intolerable. But these patients did not complain about any painful sensation. The available BC reflex was significantly delayed whether the stimulus strength was within normal limits or higher (P < 0.001) The BC reflex latency ranged between 42.5 and 100 msec, with an average of 65 msec. The shape of the reflex response was often of the single motor unit type and disclosed considerable latency variations (Fig. 6). Anal sphincter response could only be elicited in 4 cases out of the total (30~). Signs of partial or total denervation were observed by needle E M G examination in both muscles investigated.

Polyneuropathy Twenty-two cases with polyneuropathy proven by clinical findings and/or peripheral nerve conduction data were investigated. Diabetes mellitus was the cause of neuropathy in 12 cases and chronic alcoholism in 4 cases and all of them suffered especially from impotence. In other patients the disease had diverse origins or the nature of the polyneuropathy was obscure at the time of the investigation. The psychosensory response and the reflex threshold did not seem to be higher than in normal controls. The latency of the BC reflex ranged between 30 and 140 msec, with an average of 47.8 msec, which was significantly prolonged in Comparison with normal control values (P ~(0.05) but in many individual cases, the latencies were found to be still within normal limits. Although the number of patients was not sufficient for comparison, in general, the reflex latency tended to remain within the normal range in diabetic polyneuropathy while the significantly delayed reflex response could often be recorded from the alcoholic patients (Fig. 7). The external anal sphincter response was obtained in 33 ~ of the cases investigated.

Spinal cord in volvem en t Nineteen cases with spinal cord involvement were investigated. Most of the spinal lesions were caused by spinal tumour, myelitis, multiple sclerosis, motor neurone disease or progressive spastic paraparesis of unknown aetiology. Spasticity was found in different degrees and no specific localisation involving the conus medullaris was encountered on the basis of the clinical picture. Many of the patients had the sphincter disturbances and impotence. The psychosensory threshold usually rose in patients showing signs of ascending long tract involvement but the reflex threshold was as low as in normal controls. The latency of the BC reflex was usually within normal limits except in a case of multiple sclerosis. Therefore the mean latency of 36 msec did not differ significantly from normal values. In two-thirds of the subjects, the shape o f the B C reflex response was a composite of very dense polyphasic spikes and its duration was longer than in normal subjects; in some cases the response was followed by after-discharges. In parallel with this finding, a reflex response was obtained from the external anal sphincter in as many as 62.5 ~o of the spinal cases investigated (Fig. 8).

iiii!

iilili ii/ ~5

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I
Fig. 7. BC reflex from a 43-year-old male patient with an alcoholic polyneuropathy (lower trace) and from a normal 43-year-old male (upper trace). Ten superimposed sweeps. Stimulation on the glans penis, 0.2 msec and 500 V for each case. Calibration: 100/~V, 50 msec. Note the significant delay of the BC reflex in the patient.

~i~Jiljlllliil,
Fig. 8. BC reflex from a 50-year-old male patient with a spinal cord tumour (thoracic level). The intense reflex responses are recorded from the external anal sphincter (on the left) and from the BC muscle (on the right). Stimulation on the glans penis; 0.2 msec, 500 V, rate l/sec. Calibration mark: 500/tV (from peak to peak) and 10 msec (in between 2 successive positive peaks).

12

Functional or psychic impotence

Sixteen cases with functional impotence were investigated. T w o had a schizophrenic reaction and reactive depression was diagnosed in 1. Impotence was the m a j o r problem in all other cases. All cases were referred to us after a psychiatric interview. They were completely normal neurologically. In 13 out o f 16 patients, the psychosensory response and reflex threshold and the latency and shape o f the BC reflex did not significantly diffe~ from those o f the normals. The other 3 cases were very interesting and their results deviated remarkably from normal values. A l t h o u g h the psychosensory threshold in glans penis was within n o r m a l limits, the reflex thresholds were apparently high and it was not possible easily to evoke the reflex with the usual stimulation strength. In order to evoke the reflex response, stimulus shocks o f either 0.5 or 1.0 msec duration and 500 V intensity were required. Then the reflex latency was normal in 2 of the patients, while in the other a delayed response o f a b o u t 58 msec was encountered, which varied with different stimuli (Fig. 9). One o f 3 cases mentioned above was examined 3 times at almost equal intervals during 3 months. A l t h o u g h the reflex threshold was found to be high

Fig. 9. The successive BC reflexes recorded at 1 sec stimulation rate in a 38-year-old male patient with functional impotence (on the right) and in a normal 54-year-old male control subject (on the left). Stimulation on the glans penis; 0.1 msec, 500 V for normal subject and 1.0 msec. 500 V for the patient. Calibration: 100 .ttV and 50 msec. Note the apparent delay of the BC reflex in the patient.

13 in the first and in the last examination the latency of the reflex responses was within normal limits. On the other hand during the second examination, no reflex response could be elicited in spite of painful stimulation at the glans penis. This patient reported that his impotence was very severe during the period when the second examination took place. The neurological examination, EMG in leg muscles, sensory and motor conduction velocities were completely normal in these 3 cases. Their fasting blood sugar values were also within the normal range.

Miscellaneous Group
A heterogenous group of patients complaining of impotence were also included in the study. Their clinical diagnoses were as follows: Temporal lobe epilepsy in 4, Parkinson's disease in 2, shoulder girdle neuritis in l, sciatica in 1, cerebellar syndrome in 1, and partial dysautonomia in 1 patient. In the last 2 cases, the exact nature of the disorders was unclear. Only 2 cases, an epileptic and a patient with sciatica showed slight latency delay in the BC reflex; the others yielded normal electrophysiological findings.
DISCUSSION

A physiological micturition center is known to be present in the conus medullaris and the sacral part of the spinal cord which is also associated with the mechanism of sexual reflexes, especially of erection. The afferent inputs related with the urogenital skin and mucosa and the efferent signals from the sacral cord are mainly conveyed by sacral spinal roots 2, 3, and 4. Thus the anatomical and physiological segmental circuits overlap in relation to urinary and sexual functions. Such an overlapping has often been shown by experimental studies and by clinical observations (Bors and Comarr 1960; Haymaker 1969; Nashold, Friedman and Boyarsky 1971; Nashold, Friedman, Glenn, Grimes, Barry and Avery 1972). The suprasegmental facilitatory and inhibitory influences over the conus medullaris are remarkable in both functions; their suprasegmental organisation seems to be very complex and the various neurological lesions in different neural loci above the conus medullaris can produce bladder or sexual dysfunctions or both (Haymaker 1969; Bors and Comarr 1960). The electrically induced bulbocavernosus reflex reported in this study uses the anatomo-physiological circuits similar to those of the micturition and segmental sexual reflexes (Lapides and Bobbitt 1956). Therefore such a well controlled segmental reflex could first of all reflect the integrity of the sacral spinal cord related with autonomic functions, though this does not mean that it can necessarily be considered as a direct measure of micturition function nor does it necessarily reflect totally sexual spinal organisation. Nevertheless, wherever a neurogenic bladder and/or sexual dysfunction do exist the BC reflex has been found to be considerably deviated from normal parameters as presented in this study. In normal subjects the BC reflex was very stable in latency and even in wave form. It was also usually simple and not easily habituated. It appeared upon stimulation well below the pain threshold. These data indicate that the BC reflex is not

14 simply a nociceptive reflex. However, if used in clinical practice, it brings out some complex problems with regard to its practical use and interpretation. The reflex is evoked clinically by squeezing the glans penis by the examiner and usually the anal sphincter contraction is examined to ascertain its presence. Such a stimulus is somewhat painful to the patient but this may be acceptable if it is the only way to evoke a reflex contraction of the external anal sphincter. Used clinically in this way, the reflex, in addition to being a painful procedure, does not give reliable intbrmation about the neural integrity of the sacral spinal cord. In addition, palpation of the BC muscle through the perineal skin can sometimes be difficult in obese patients and the contraction of this tiny muscle may not easily be felt. Thus the electrically induced and recorded BC reflex is a very stable and reliable method of diagnosing a neurogenic bladder and/or organic impotence. It should be included among the other methods of investigating neurogenic bladder dysfunction such as cystometric evaluation and E M G examination of the anal and urethral sphincter muscles. On the basis of our conduction velocity results along the penis, the afferent pudendal nerve fibres which mediate the BC reflex seem to belong to the A-delta group of small diameter myelinated fibres. But the short distances involved in measurements would probably not allow us to be certain of this point. The efferent limb of the reflex is also carried out by the pudendal motor nerve fibres, and motor conduction velocity along the pudendal nerve was found to be 56-57 m/sec by Chantraine0 De Leval and Onkelinx (1973). Investigation of the BC reflex yielded some interesting and practical clinical data on our patients. When the reflex arcs was broken, no response was present as in cases of cauda equina lesions in which the bladder and the sexual reflexes are predominantly disturbed. If the nerve fibres carrying the afferent and efferent reflex impulses were not completely destroyed and some impulse conduction was still present, the BC reflex was prolonged as in some cases of cauda equina lesion, or polyneuropathy. The latter cases behaved in two different ways. The latency of the BC reflex was significantly increased in some cases especially in alcoholics, while the reflex response did not differ significantly from normal in diabetic neuropathy. Whereas patients in both groups suffered from impotence of varying degree of impotence, our results suggest that impotence seen in diabetes mellitus is mainly due to involvement of autonomic nerve fibres, while that associated with alcoholic polyneuropathy could well be due to disorders of the somatic sacral nerve fibres. Since polysynaptic cutaneous reflexes are exaggerated in spasticity, our finding of an intense BC reflex with after discharges and the high percentage of cases of spinal cord lesion in which reflex responses were obtained from the striated anal sphincter may be related to such a general hyperreflexia. The BC reflex was found to be within the normal range in all but 3 patients with functional impotence. These 3 cases seemed to be unique examples indicating that the spinal reflex centre could sometimes be strongly controlled, and even suppressed by supraspinal influences. Such a supraspinal inhibition of the BC reflex can easily be distinguished from the changes seen in cases of cauda equina lesion on the

15 basis of the clinical picture, by E M G e x a m i n a t i o n of the sphincters and by nerve c o n d u c t i o n studies in the peripheral nerves. The clinical neurological findings a n d the electrophysiological investigations just m e n t i o n e d would be f o u n d to be completely n o r m a l in such a case of functional impotence. Thus in any case of impotence, investigation of the BC reflex assumes special importance as an objective tool in refining the diagnostic ability of the clinician for whom sexual dysfunction is sometimes a difficult p r o b l e m ; it may be difficult to determine whether it is caused by neurogenic or psychological factors, especially when the sexual history taken from the patient provides the only available data u p o n which to base clinical interpretation.

REFERENCES Bors, E. H. and K. A. Blinn (1957) Spinal reflex activity from the vesical mucosa in paraplegic patients, Arch. Neurol. Psychiat., 78: 339-354. Bors, E. H. and K. A. Blinn (1959) Bulbocavernosus reflex, J. Urol. (Balthnore), 82: 128-130. Bors, E. H. and A. E. Comarr (1960) Neurological disturbances of sexual function with special reference to 529 patients with spinal cord injury, Urol. Surv., 10: 191-222. Chantraine, A., J. De Leval and A, Onkelinx (1973) Motor conduction velocity in the internal pudendal nerves. In: J. E. Desmedt (Ed.), New Developments in Electromyography and Clinical Neurophysiology, Vol. 2, Karger, Basel, pp. 433 438. Haymaker, W. (1969) Bing's Local Diagnosis in Neurological Diseases, Mosby, Saint Louis, Mo. Lapides, J. and J. M. Bobbitt (1956) Diagnostic value of bulbocavernosus reflex, J. Amer. reed. Ass., 162:971 972. Nashold, Jr., B. S., H. Friedman and S. Boyarsky (1971) Electrical activation of micturition by spinal cord stimulation, J. surg. Res., 11:144 147. Nashold, Jr., B. S., H. Friedman, J. F. Glenn, J. H. Grimes, W. F. Barry and R. Avery (1972) Electromicturition in paraplegia - - Implantation of a spinal neuroprosthesis, Arch. Surg., 104:195 202. Petersen, 1. and 1. Stener (1970) An electromyographical study of the striated anal sphincter, and the levator ani muscle during ejaculation, Electromyography, 10: 23-44. Pierce, Jr., J. M., J. T. Roberge and M. M. Newmann (1960) Electromyographic demonstration of bulbocavernosus reflex, J. UroL, 83: 319. Ratner, W. H., R. L. Gerlaugh, J. J. Murphy and W. J. Erdman (1958) The bulbocavernosus reflex - - Electromyographic study of normal patients, J. Urol., 80: 140-141. Rushworth, G. (1967) Diagnostic value of the electromyographic study of reflex activity in man. In: L. Wid6n (Ed.), Recent Advances in Clinical Neurophysiology, Supplement No. 25 to Electroenceph, olin. Neurophysiol., Elsevier, Amsterdam, pp. 65-73.