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Neurogenic Voiding Dysfunction. Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital. Complications of Neurogenic voiding dysfunction. Severe lower urinary tract symptoms: dysuria, incontinence, retention Urinary tract infection: APN, cystitis, prostatitis, epididymitis

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Neurogenic Voiding Dysfunction

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Neurogenic voiding dysfunction l.jpg

Neurogenic Voiding Dysfunction

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital


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Complications of Neurogenic voiding dysfunction

  • Severe lower urinary tract symptoms: dysuria, incontinence, retention

  • Urinary tract infection: APN, cystitis, prostatitis, epididymitis

  • Renal function impairment: hydronephrosis, vesicoureteral reflux, renal scarring, ESRD


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Objectives of urological care for neurogenic voiding dysfunction

  • Preservation of renal function

  • Adequate bladder emptying

  • Prevention of UTI

  • Establishment of continence

  • Freedom of catheter

  • Spontaneous voiding


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Treatment of NVD

  • Based on pathophysiology of NVD

  • Patient’s self-handling capability

  • Family support

  • Convenience of medical care

  • Patient’s will of management


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Neurogenic Voiding Dysfunction

(1997-2002)


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Symptomatology of Neurogenic Voiding dysfunction


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Normal Micturition

  • Cortical arousal and initiation of voiding

  • Normal detrusor contractility

  • Normal cortical inhibition before voiding

  • Patent bladder outlet and urethra

  • Coordinated external sphincter during detrusor contraction

  • Volitional contraction of sphincter and interruption of voiding


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Normal Micturition


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Physiology of Micturition

  • Micturition reflex center – sacral cords S2-4

  • Micturition center – pons

  • Sensory and motor cortex – frontal lobe

  • Coordination of detrusor and striated sphincter – cerebellum,basal ganglia

  • Affection influence – limbic system


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Diagram of Micurition reflex


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Urodynamic Classification NVD

  • Cerebral lesion – detrusor areflexia; detrusor hyperreflexia with coordinated external sphincter

  • Suprasacral cord lesion– autonomic dysreflexia (lesion above T6); detrusor hyperreflexia with external sphincter dyssynergia


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Urodynamic Classification NVD

  • Sacral cord lesion – detrusor areflexia with non-relaxing urethra; atonic urethra

  • Peripheral neuropathy – detrusor areflexia with discoordinated urethral sphincter


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Urodynamic findings in Neurogenic Voiding dysfunction


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Cerebral control of micturition

大腦前葉

小腦

橋腦排尿中樞


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Classification of NVD-- Krane & Siroky 1979

  • Detrusor hyperreflexia

    Coordinated sphincter

    Striated sphincter dyssynergia

    Smooth muscle sphincter (BN) dyssynergia

  • Detrusor areflexia –

    Coordinated sphincter

    Non-relaxed striated sphincter

    Denervated striated sphincter

    Non-relaxing smooth muscle sphincter (BN)


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Sphincter corrdination in Neurogenic Voiding Dysfunction


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Urinary tract Abnormalitie Neurogenic Voiding Dysfunction


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Micturition reflex and Nervous pathways

橋腦排尿中樞PONS

胸腰髓T10-L2

薦髓

薦髓S2,3,4

骨盆底神經

陰部神經


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Stroke

  • Initial retention, bladder neck is closed

  • Detrusor hyperreflexia & incontinence

  • Continence reappears by 6 Mo in 80%

  • Irritative LUTS: DH

  • Dysuria and obstructive LUTS: DHIC,BPO, poor relaxation of external sphincter (frontoparietal & internal capsule lesion)

  • Subcortical lesion: areflexia, retention (47%)

  • Areflexia in 85% hemorrhage, 10% ischemia


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Stroke and Bladder outlet obstruction

  • Detrusor hyperreflexia in 82% after stroke, obstruction was noted in 63%

  • Pseudodyssynergia may be a urodynamic finding for obstructive symptoms

  • Incidence of BOO is equally distributed in patients with irritative and obstructive LUTS

  • Prostatectomy should not be done in 1 year after stroke


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Detrusor areflexia at initial stage of Stroke


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Prostatic obstruction in Stroke


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Pseudodyssynergia in Stroke


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Intracranial Diseases and NVD

  • Cerebral vascular accidents – DH

  • Parkinson’s disease – DH, ext. sphincter pseudodyssynergia

  • Cerebellar ataxia – DH, DESD

  • Cerebral palsy – normal voiding, DH

  • Dementia – DH, DHIC, DA

  • Recurrent stroke – DH,DHIC, DA


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Urodynamic findings in ICD

  • Detrusor hyperreflexia – lack of inhibitory effect

  • Detrusor areflexia –initial post-stroke period, failure of initiation ability in chronic case

  • Decreased ability in initiation at small voided volume -- hesitancy

  • Decreased ability of voluntary sphincter contractions -- incontinence

  • Sphincter coordination is normal – no DESD

  • Normal detrusor pressure, low/normal flow


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Development of Low Compliance bladder after CVA


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Recovery of detrusor contraction after stroke


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Multiple Sclerosis

  • Detrusor hyperreflexia occurs in 60-70%, DESD in 20-40%, hypocontractility in 15-40%

  • Lower urinary tract dysfuncton affect 80% of MS patients, rising to 96% after 10 years of MS

  • Symptoms wax and wan

  • Incontinence & dysuria the main LUTS


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DESD in Multiple Sclerosis


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Diabetes mellitus

  • Detrusor hypocontractility in 35%

  • Detrusor hyperreflexia in 55-60%

  • Detrusor areflexia in chronic DM

  • Increased incidence of bladder outlet obstruction in chronic cases

  • When TURP is attempted, prostatic obstruction should be confirmed by videourodynamic study


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Low Detrusor Contractility in Diabetes Patient


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Parkinson’s Disease

  • Detrusor hyperreflexia and frequency urgency

  • External sphincter pseudodyssynergia results in poor relaxation and difficult initiation of voiding

  • DHIC in severe case

  • Symptoms wax and wan with treatment


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DHIC in Parkinson’s disease


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Detrusor hyperreflexia with BPO in Parkinson’s disease


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Other conditions

  • Transverse myelitis – sudden onset of dysuria and retention, reversible, DH, DESD,DA can be found in urodynamics

  • In 39 HIV positive patients 87% had urodynamic abnormality: 62% due to toxoplasmosis encephalitis and DH, half of them could recover after treatment


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Bladder neck dysfunction and DESD in Spinal cord lesion


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DESD and low contractility in Incomplete Cervical SCI


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Management of NVD following stroke and ICD

  • Indwelling Foley catheter in initial stage

  • Clean intermittent catheterization

  • Urodynamic test after recovery of motor function

  • Avoid bladder overdistention to 500ml

  • Trocar cystostomy in male patients

  • Alpha-blocker and urecholine therapy


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Clean intermittent (self) catheterization (CIC, CISC)

  • Easy to perform when properly instructed

  • Adequate lubrication is necessary

  • Will not exacerbate UTI occurrence

  • Bladder capacity and intravesical pressure should be determined before institution of CIC


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Clean Intermittent Catheter


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Indwelling catheter andTrocar cystostomy

  • Easy to care in debilitative patients

  • Frequent exchange of catheter is needed

  • Stone formation and symptomatic UTI

  • Contracted bladder and VU reflux

  • Fecal soiling in female patients

  • Surgical complication in trocar cystostomy

  • Mucosal dysplasia and bladder cancer


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Trocar Cystostomy

導引器外套

膀胱

前列腺

直腸


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Advantage and disadvantages of Trocar cystostomy

  • Facilitate voiding training

  • Free of genital tract infection

  • Free of fecal soiling in women

  • Minimally invasive procedure

  • Regular local treatment and replacement

  • Risk of bowel perforation

  • Granuloma formation around catheter


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Medical Treatment

  • Increase detrusor muscle tone -- bethanechol

  • Decrease detrusor hyperreflexia – oxybutynin, tolterodine, imipramine, flavoxate, dicyclomine

  • Decrease outlet resistance – alpha-adrenergic blocker, skeletal muscle relaxant, nitric oxide donors

  • Increase outlet resistance – methylephedrine, imipramine


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Medical treatment for detrusor instability & inadequate contractility

  • Existence of bladder outlet obstruction

  • Residual urine amount

  • Patient’s ability of abdominal straining

  • Patient’s ability of performing CISC

  • General condition

  • Adjust combination of anticholinergics and alpha-blocker


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Intravesical therapy for DH

  • Intravesical oxybutynin (ditropan)

  • Electromotive treatment of oxybutynin

  • Resiniferatoxin therapy (10-6 ~ -7M RTX)

  • Detrusor injection of botulinum toxin – 200-300 IU Botox or 500 U Dysport injected to detrusor muscles at 20-30 sites


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Effects of resiniferatoxin in DH


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Idiopathic Detrusor failure

  • Occult neuropathy or myopathy

  • Detrusor underactivity in the elderly

  • Urinary retention developed after major surgery or diseases

  • Bladder overdistention during TURP or major surgery

  • Recovery takes time maybe 3-6 months


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Idiopathic Detrusor Instability & Underactivity after Surgery


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Treatment of idiopathic NVD

  • Search for bladder outlet obstruction & Peripheral neuropathy, especially in old women

  • CISC or trocar cystostomy

  • Urecholine & alpha-blocker

  • Try nitric oxide donors to facilitate void

  • Periurethral botulinum toxin injection 50- 100 units to avoid catheterization


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Botulinum A toxin


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Botulinum A Toxin Injection in Woman


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Cystoscopic Urethral Injection in Men

*

*

*

*


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Reduced abdominal voiding pressure after botulinum toxin


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Recovery of detrusor contractility in detrusor underactivity


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Surgical treatment for NVD

  • TURP in male and TUI-BN in women with NVD due to definite bladder outlet obstruction

  • External sphincterotomy in quadriplegia and chronic debilitative patients

  • Intraurethral stent for high risk patients

  • Urinary diversion


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BPO in a Man after Stroke


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Urinary incontinence exacerbates after TURP in DH


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Considerations in management of neurogenic voiding dysfunction

  • Lower urinary tract dysfunction changes with time

  • Avoid overdistention and recurrent cystitis during recovery period

  • Avoid unnecessary surgery

  • Regular urodynamic follow-up and determine proper volume in CIC

  • Do not abandon patients with NVD


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Improved Detrusor contractility after acute Stroke


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