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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

Neurogenic Voiding Dysfunction

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital

complications of neurogenic voiding dysfunction
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
objectives of urological care for neurogenic voiding dysfunction
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
treatment of nvd
Treatment of NVD
  • Based on pathophysiology of NVD
  • Patient’s self-handling capability
  • Family support
  • Convenience of medical care
  • Patient’s will of management
normal micturition
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
physiology of micturition
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
urodynamic classification nvd
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
urodynamic classification nvd12
Urodynamic Classification NVD
  • Sacral cord lesion – detrusor areflexia with non-relaxing urethra; atonic urethra
  • Peripheral neuropathy – detrusor areflexia with discoordinated urethral sphincter
cerebral control of micturition
Cerebral control of micturition

大腦前葉

小腦

橋腦排尿中樞

classification of nvd krane siroky 1979
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)

micturition reflex and nervous pathways
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

stroke
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
stroke and bladder outlet obstruction
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
intracranial diseases and nvd
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
urodynamic findings in icd
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
multiple sclerosis
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
diabetes mellitus
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
parkinson s disease
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
other conditions
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
management of nvd following stroke and icd
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
clean intermittent self catheterization cic cisc
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
indwelling catheter and trocar cystostomy
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
trocar cystostomy
Trocar Cystostomy

導引器外套

膀胱

前列腺

直腸

advantage and disadvantages of trocar cystostomy
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
medical treatment
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
medical treatment for detrusor instability inadequate contractility
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
intravesical therapy for dh
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
idiopathic detrusor failure
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
treatment of idiopathic nvd
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
surgical treatment for nvd
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
considerations in management of neurogenic voiding dysfunction
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
ad