Neurogenic voiding dysfunction
1 / 60

Neurogenic Voiding Dysfunction - PowerPoint PPT Presentation

  • Updated On :

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

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Neurogenic Voiding Dysfunction' - janae

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Neurogenic voiding dysfunction l.jpg

Neurogenic Voiding Dysfunction

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital

Complications of neurogenic voiding dysfunction l.jpg
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 l.jpg
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 l.jpg
Treatment of NVD

  • Based on pathophysiology of NVD

  • Patient’s self-handling capability

  • Family support

  • Convenience of medical care

  • Patient’s will of management

Symptomatology of neurogenic voiding dysfunction l.jpg
Symptomatology of Neurogenic Voiding dysfunction

Normal micturition l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
Urodynamic Classification NVD

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

  • Peripheral neuropathy – detrusor areflexia with discoordinated urethral sphincter

Urodynamic findings in neurogenic voiding dysfunction l.jpg
Urodynamic findings in Neurogenic Voiding dysfunction

Cerebral control of micturition l.jpg
Cerebral control of micturition




Classification of nvd krane siroky 1979 l.jpg
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)

Sphincter corrdination in neurogenic voiding dysfunction l.jpg
Sphincter corrdination in Neurogenic Voiding Dysfunction

Micturition reflex and nervous pathways l.jpg
Micturition reflex and Nervous pathways







Stroke l.jpg

  • 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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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

Dhic in parkinson s disease l.jpg
DHIC in Parkinson’s disease

Other conditions l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
Trocar Cystostomy





Advantage and disadvantages of trocar cystostomy l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
Intravesical therapy for DH contractility

  • 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 l.jpg
Idiopathic Detrusor failure contractility

  • 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 l.jpg
Treatment of idiopathic NVD Surgery

  • 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

Cystoscopic urethral injection in men l.jpg
Cystoscopic Urethral Injection Surgeryin Men





Surgical treatment for nvd l.jpg
Surgical treatment for NVD Surgery

  • 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 l.jpg
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