Dynamic Bulbocavernosus Reflex: Dyssynergia Evaluation Following SCI

ABSTRACT

High urethral resistance caused by detrusor-sphincter dyssynergia (DSD) occurs following spinal cord injury (SCI) and results in poor voiding. A major pelvic floor reflex that may be involved in DSD is the bulbocavernosus reflex (BC) and evaluation of this reflex during the micturition cycle may provide additional information regarding this role. The periodic BC observed during micturition via cystometry is described as a dynamic bulbocavernosus reflex (DBC).

The DBC was induced in upper motor neuron SCI patients using periodic dorsal penile nerve stimulation; the evoked reflex response was recorded with an anal sphincter pressure sensing balloon. Stimulation of 15–50 mA was applied at the base and dorsal side of the penis with surface electrodes, pulsed at a rate of 0.25 Hz. By applying the stimulation during cystometry, the BC reflex could be evaluated throughout the entire micturition cycle. Results showed that the DBC increased during bladder filling and bladder contractions. These findings indicate that an enhanced BC reflex is a major factor causing increased urethral resistance during micturition. (J Am Paraplegia Soc: 17; 140–145)     

Botulinum Toxin Injections for Voiding Dysfunction Following SCI

Abstract

Botulinum toxin (BT) injections have been used successfully to treat spastic muscle conditions, including detrusor- sphincter dyssynergia (DSD) seen in spinal cord injury (SCI) patients. In our urology clinic, we used BT to treat three SCI patients who had voiding dysfunction, using a transperineal needle with electromyographic (EMG) monitoring. Two of the patients reported excellent results following the treatment. One patient, with whom the staff had difficulty doing intermittent catheterization (IC), improved significantly. The other patient had improved voiding with an external catheter and minimal urinary residual. The third patient had no improvement of leg spasms with his voiding dysfunction and required a sphincterotomy. Although patients may need repeat injections, BT is minimally invasive and easy to administer with no side effects. Overall, BT injection is an excellent method of managing voiding in SCI patients, especially those on continuous external catheters and with IC management who refuse or are not good candidates for surgery.     

Urologie Manifestation of Spinal Cord Sarcoidosis

abstract

We present the first report of neurogenic lower urinary tract dysfunction associated with neurosarcoidosis. Urodynamic findings of detrusor hyperreflexia with detrusor-sphincter dyssynergia correlate with this patient’s magnetic resonance imaging (MRI) examination which found intramedullary involvement at the mid-thoracic level. (J Spinal Cord Meet, 19:201–203)     

Intravesical Capsaicin in Neurologic Impaired Patients With Detrusor Hyperreflexia

ABSTRACT

Capsaicin is known to be neurotoxic for C-fiber afferents. We investigated the intravesical application of capsaicin in the treatment of detrusor hyperreflexia (DH) in seven patients (ages 23–52) with neurologic impairment. The patients were evaluated with both ice-water cystometry and formal video-urodynamic studies. Four biweekly courses of intravesical capsaicin treatment were administered using increasing concentrations (100 μM, 500 μM, 1 mM and 2 mM). Treatment effect was monitored using a bladder diary and urodynamic evaluation one month after capsaicin treatment. Prior to treatment, six of the seven patients demonstrated a positive ice-water test and DH. Two patients were not able to complete the study due to discomfort attributed to capsaicin. Five of the seven patients completed the four courses of increasingly concentrated capsaicin. Three patients noted symptomatic improvement while two did not. The mean urodynamic bladder capacity significantly increased from 124±39 ml pre-capsaicin to 231 ±62 ml one month post-cap-saicin in the three patients with symptomatic improvement (p<0.05). Urodynamic testing revealed that one of the six patients with a positive ice-water test lost that response after intravesical capsaicin. Intravesical capsaicin is a novel and promising treatment for detrusor hyperreflexia in neurologically impaired patients. (J Spinal Cord Med\ 19:190–193)     

Long‐term effects of repeated intradetrusor botulinum neurotoxin A injections on detrusor function in patients with neurogenic bladder dysfunction

OBJECTIVE

To evaluate the influence of repeated botulinum neurotoxin A (BoNT‐A) treatments on detrusor function in patients with neurogenic detrusor overactivity (DOA) due to spinal cord lesions.

PATIENTS AND METHODS

In a retrospective study, urodynamic evaluations of 27 consecutive patients with neurogenic DOA due to spinal cord lesions who received at least five BoNT‐A treatments were analysed.

RESULTS

After the first BoNT‐A treatment, bladder capacity, reflex volume, continence status and detrusor compliance were significantly improved and maximum detrusor pressure (P_detmax) was significantly reduced. The mean number of BoNT‐A treatments was 7.1. Compared with the results of the first treatment, the incontinence rate (seven patients) and the number of patients with an elevated P_detmax (five patients) were slightly increased after the final BoNT‐A treatment. The long‐term success rate was 74%. Every fourth patient needed a major surgical intervention. There was a significant decrease in P_detmax before BoNT‐A treatments, indicating that detrusor contraction strength did not completely recover after treatment.

CONCLUSIONS

Our study confirmed the long‐term efficacy of repeated BoNT‐A treatments in patients with neurogenic DOA. However, in long‐term follow‐up, every fourth patient required surgical interventions. Moreover, our data give the first hint that BoNT‐A may lead to impaired detrusor contraction strength, which could influence future treatment options. Prospective studies are necessary to elucidate the impact of repeated BoNT‐A treatments on detrusor function and the interactions with future treatment options.     

In-Vivo Whole Bladder Response to Anticholinergic and Musculotropic Agents in Spinal Cord Injured Rats

Abstract

The purpose of this study was to compare the effect on urodynamic parameters of anticholinergic and musculotropic agents in sham injured and spinal cord injured (SC I) rats. A standard rat SCI model induced by impact trauma was employed. Cystometrograms were performed under urethane anesthesia four weeks after SCI. Bladder capacity and voiding pressure were determined at the point of micturition monitored urodynamically and visually. The effect of oxybutynin chloride (0.01 - 0.1 mg/kg), propantheline bromide (0.05 - 0.5 mg/kg) and flavoxate hydrochloride (0.1 - 1.0 mg/kg) were assessed independently in sham injured and SCI rats (n = 1 0 in each group). Bladder capacities were 0.6± 0.2 and 7.1± 1.6 ml in sham and SCI rats (p <0.01 ), respectively. Maximal filling pressure was 17.5±5 mmHg in sham and 25±5 mmHg in SCI rats (p <0.05). Bladder capacity increased with all three medications. Administration of oxybutynin, propantheline and flavoxate in sham rats resulted in bladder capacities of 0.88±0.3, 0.71±0.3 and 0.8± 0.2 ml, respectively (p <0.01 ). In SCI rats, these drugs resulted in bladder capacities of 9.8± 1.1, 7.9± 1.3 and 8.8±2.0 ml , respectively (p <0.01 ). No significant change in maximum filling pressure occurred. We conclude that anticholinergic and musculotropic agents caused a similar increase in bladder capacity in both sham and SCI rats. Oxybutynin enhanced bladder capacity more than propantheline or flavoxate. (J Spinal Cord Med 1997; 20:31-35)     

Optimization of Sacral Ventral Root Stimulation Following SCI: Two Case Reports with Six-Month Follow-Up

Abstract

Sacral ventral root stimulation in conjunction with sacral dorsal rhizotomy has been effective in promoting voiding in individuals with upper-motor-neuron spinal cord injury. We report on two patients who had variable voiding responses to stimulation during the first six months after electrode implantation. We used videourodynamic records and daily voiding records to characterize their voiding difficulties. Different methods were used to improve voiding, including seating adjustments and changes in stimulation parameters. The first patient was unable to empty his bladder on a regular basis with stimulation using 24 pulses per sec stimulating frequency for the first two months after implantation. Voiding was substantially improved by using 35 pulses per sec. At the end of six months, he is regularly emptying his bladder with stimulation and is on an every-second-day bowel program. However, his bowel program has been irregular. The second patient had very good voiding when stimulation was applied in bed, but he had poor voiding with high residual volumes when sitting in his wheelchair. Voiding was improved when he used a wheelchair cushion that was cut out in the back or lifted his buttocks off the chair. These procedures appeared to reduce perineal pressures. This patient has bowel care on alternate days and his bowel care time has been reduced following implantation of the device. Neither of the patients experienced an erection with the device. Both patients feel positive about their implant experience.     

Direct Bladder Stimulation with Percutaneous Electrodes and Impedance Monitoring of Volume in an SCI Animal Model

Abstract

Bladder responses to percutaneous electrodes were investigated with stimulation in three male spinal cats. The animals had been spinalized (T1 level lesion) 10 weeks prior to these studies and had been instrumented with chronic bladder wall electrodes and suprapubic bladder catheters for filling and pressure recording. Percutaneous stimulation in tethered animals was conducted with hook electrodes inserted with a needle in the abdomen bilaterally adjacent to the bladder trigone. Stimulation was conducted with 40 Hz pulse trains of 10 to 30 mA for three seconds. Stimulation with both percutaneous and chronic electrodes induced high bladder pressures and voiding. In addition, with chronically implanted electrodes, impedance monitoring of bladder volume was found to be an effective recording technique. (J Spinal Cord Med; 18:98–102)     

Urological manifestations of chronic schistosomal myeloradiculopathy

OBJECTIVE: To describe the clinical and urodynamic features of patients with chronic voiding dysfunction secondary to schistosomal myeloradiculopathy (SM), as the clinical involvement of the spinal cord is a well recognized complication of Schistosomiasis mansoni infection. PATIENTS AND METHODS: We reviewed the records and urodynamic studies of 26 consecutive patients (17 males and nine females, aged 8-58 years) with chronic neurological and urinary symptoms secondary to SM. The voiding function history, radiological and urodynamic findings and therapeutic approaches were reviewed. Patients with and without upper urinary tract complications were compared in terms of age, duration of voiding dysfunction and urodynamic pattern. RESULTS: The most common urinary symptoms were difficulty in emptying the bladder (17 patients, 65%), urinary incontinence (14, 54%), and urgency and frequency (13, 50%). Laboratory and radiographic evaluation showed urinary tract infection in eight (30%) patients, bilateral hydronephrosis in five (19%) and bladder calculi in five (19%). Urodynamics showed detrusor overactivity with detrusor-external sphincter dyssynergia (DESD) in 14 patients (54%), detrusor arreflexia in six (23%), detrusor overactivity with no dyssynergia in four (15%), and detrusor underactivity in two (8%). Comparing patients with and without upper tract complications showed no differences in age and duration of urinary symptoms, but there was a significant association of detrusor overactivity with DESD and upper urinary tract complications (P = 0.04). Urological management consisted of antibiotics, clean intermittent catheterization, anticholinergic medication and stone removal, as appropriate. Conservative treatment failed in three patients and they required an injection with botulinum-A toxin into the detrusor (two) or ileocystoplasty (one). CONCLUSION: Patients with chronic SM behave clinically like those with other causes of spinal cord disease and neurogenic bladder dysfunction requiring lifelong surveillance. The severity of illness in these patients should re-emphasize the need for early recognition and treatment of this condition, to prevent or reverse the neurological deficits.     

Detrusor-myoplasty,innervated rectus muscle transposition study,and functional effect on the spinal cord injury rat model

The purpose of this investigation was to determine the feasibility of striated muscular augmentation of the urinary bladder (detrusor-myoplasty, DMP). Initial studies, transposition, and bladder wrap using several distinct muscle groups was attempted in laboratory rats, goats, and fresh human cadavers. The rectus abdominus muscle was found to be best suited to completely encompass the bladder with an intact neural and vascular supply. The technique was then applied in a rat model of spinal cord injury (SCI). Modified Tarlov ratings were employed to assess neurologic function 30 days after SCI. The median final neurological score of SCI rats with and without DMP was 4 and 5, respectively. Sham-operated SCI (control) rats, with and without DMP, both had normal final Tarlov scores of 12 (P < 0.05). Muscle blood flow values for the flap and the contralateral undissected rectus muscles were not significantly different (97 ± 34 and 105 ± 40 ml/100 g tissue/min, respectively, P = 0.47). Postoperatively, no bowel or abdominal wall functional deficits were apparent. The rotated muscular flap remained innervated and vascularized. Analysis of 24 hr micturition patterns demonstrated no differences in oral fluid intake/24hr. voided volume/24hr, and ratio of number of micturitions during the night vs. day among the four groups: (1) control (neither SCI nor DMP), (2) DMP only, (3) SCI only, and (4) SCI with DMP. Spinal cord injured rats with and without detrusor-myoplasty demonstrated a significant decrease in the number of micturitions/24hr, an increased volume per micturition, and greater largest and smallest micturition volumes (P < 0.05) when compared to controls. The micturition patterns among SCI rats with and without DMP were similar, as were non-SCI animals with and without DMP. This is the first report of the principle and technique of detrusor-myoplasty. Dissection of rats, goats, and human cadavers revealed that a vascularized and innervated rectus muscle flap can be rotated into the pelvis and wrapped around the bladder without tension. Significant loss of bladder capacity did not occur with skeletal muscle adaptation. Detrusor-myoplasty may be applicable for patients with an areflexic detrusor and non-intact sacral motor roots who are not candidates for sacral anterior root neurostimulation. © 1994 Wiley-Liss, Inc.     

光感基因调控技术对大鼠骶上脊髓损伤后膀胱尿动力学和肌电图的影响

目的观察光感基因调控技术对大鼠骶上脊髓损伤所致神经源性膀胱功能的影响。方法 50只大鼠经尿流动力学检查无异常后进行随机分组,并采用T10脊髓完全横断建立脊髓损伤动物模型,分为假手术对照组、脊髓损伤无蓝光刺激组和脊髓损伤蓝光刺激组。2周后进行膀胱尿动力学、肌电图测定。结果脊髓损伤蓝光刺激组大鼠膀胱逼尿肌肌条舒缩曲线大部分可见规律性变化,波形均匀一致;同时膀胱最大容量增加,内压降低,顺应性升高;而脊髓损伤无蓝光刺激组无上述变化。结论光感基因可以调节骶上脊髓完全性损伤后膀胱逼尿肌的收缩功能,对神经源性膀胱功能恢复有重要意义。     

Autonomic dysreflexia in a rat model spinal cord injury and the effect of pharmacologic agents

The object of this study was to develop a spinal cord injury (SCI) rat model for autonomic dysreflexia (AD), assessing the effect of alpha-adrenergic and calcium channel blockade and to determine the relationship of detrusor-external sphincter dyssynergia (DKSD) to the development of AD. A laminectomy was performed in male rats at the T4 or TI0 level and a controlled 50 g cm blunt SCI was induced using an impounder. Four weeks after injury, changes in arterial blood pressure and heart rate were monitored while simultaneous cystometry (CMG) and pelvic floor electromography (EMG) were performed in vivo in sham (control) and spinal cord injured rats. The effects of terazosin (0.1 mg/kg). diltiazem (0.5 mg/kg). and oxybutynin chloride (0.1 mg/kg) on hemodynamic changes were assessed independently. Both T4 and TI0 SCI rat displayed evidence of DESD (enhanced pelvic floor EMG activity at cystometric capacity) while control rats did not. Only T4 injured rats exhibited evidence of AD, with mean blood pressure elevations from 82.9 ± 13.6 to 93.9 ± 11.3 mm Hg (P < 0.01) and a mean heart rate decrease from 332.2 ± 56.5 to 311.1 ± 54.5 beats/min (P = 0.02) at cystometric capacity. The intravenous administration of terazosin or diltiazem abolished the AD response during CMC. The administration of oxybutynin exhibited the ability to increase bladder capacity and improve compliance in all 3 groups but did not blunt AD. The rat model of SCI effectively reproduced hemodynamic changes consistent with the AD complex in T4 level SCI but not TI0 level SCI animals, despite incomplete lesions. Blockade with either an alpha-1 or a calcium channel antagonist effectively ablated the AD response to bladder distention. Anticholinergic agents had no effect on AD DESD frequently accompanies autonomic dysreflexia, although the development of AD is not a prerequisite for DESD. © 1995 Wiley-Liss, Inc.     

Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury

AIMS: The vast majority of spinal cord lesions cause neurogenic bladder disorders. Detrusor hyperreflexia presents a major risk factor for renal damage in these patients. We evaluated the long-term results of patients with spinal cord injury treated at our institution. METHODS: Eighty spinal cord injury patients (60 male, 20 female; mean age 29.6 years) with at least one follow-up visit a year for a minimum of five consecutive years, were included in this retrospective analysis. Follow-up included urodynamic evaluation, sonography of the upper and lower urinary tract, urine examination, and evaluation of renal function. Treatment modifications were based on the urodynamic findings. RESULTS: Mean follow-up was 67.3 months (range 60-103 months). At initial presentation, 51 patients performed intermittent catheterization, 7 had indwelling catheters, 10 utilized reflex voiding, 2 patients presented with a Brindley stimulator, 10 patients used abdominal straining. At the end of our study, no patient had signs of renal damage. To achieve that goal, 8 patients underwent sphincterotomy, 3 received a Brindley stimulator, 3 underwent bladder augmentation, one Kock pouch was performed, and 12 patients were treated with botulinum-A-toxin injections in the detrusor. Twenty-two patients received intravesical anticholinergic therapy. In merely three patients, treatment was not modified during the entire follow-up. CONCLUSIONS: In the long term, treatment strategy of neurogenic bladder dysfunction in patients with spinal cord injury had to be modified in almost all patients. 18.8% underwent surgery. For protection of the upper urinary tract and maintenance of continence, regular urodynamic follow-up is warranted.     

Bulbocavernosus muscle responses after suprapubic stimulation: analysis and measurement of suprapubic bulbocavernosus reflex latency

Our objective was to describe pelvic floor responses with measurement of reflex latency after suprapubic mechanical stimulation. Twenty-one patients without neurological disease were studied. They were 14 women and seven men. The mean age was 51 (SD = 14.2). Motor responses were recorded with a needle electrode inserted in the left bulbocavernosus muscle. Stimulation was delivered with an electromechanical hammer, tapping directly on the suprapubic area. A polyphasic muscular response was always easily elicited in all patients. The man latency was 67.5 milliseconds (SD = 14.7). The reproducibility between the first and second mechanical responses was good with no statistical difference (r=0.966;P = 0.0001). In three patients who underwent cystometry, no rise in detrusor pressure was observed during mechanical stimulation of the suprapubic area. Our study clearly demonstrates a suprapubic bulbocavernosus reflex (SBR). Tapping the suprapubic area is a strong stimulus, reflexively mediated, used in the management of neurogenic bladder to determine a bladder contraction. However, the reflex consisting of pelvic floor muscle contraction after suprapubic stimulation was not specifically studied in humans. Many arguments can be put forth for a polysynaptic reflex (polyphasic response, habituation and short latency of the reflex, mean latency in the habitual values of R2 responses after electrical stimulation of the dorsal nerve of the penis). We hypothesize that the true stimulus is the stimulation of the bladder wall tensoreceptors, the integration level of the SBR is the sacral segments and the efferent limb the pudendal nerve, and afferent pathways could be conducted by pelvic nerve fibers. Competition between a preponderant (or exaggerated) SBR and a bladder contraction after suprapubic tapping may constitute an equivalent of detrusor-sphincter dyssynergia in some suprasacral bladders.     

Urodynamic and physiologic patterns associated with the common causes of neurogenic bladder in adults

The clinical presentation of the neurogenic bladder can be as vast as the pathologic causes however urodynamics (UDS) can help guide clinical decision-making and help simplify a complex disease state. UDS may be considered as the gold standard in helping to break down complex and multifactorial voiding dysfunction into manageable goals; these include protecting the upper tracts, limiting urinary tract infections (UTI) via avoiding urinary stasis, and maintaining quality of life. Included within are examples of normal to pathologic tracings including normal filling and voiding, detrusor sphincteric coordination, changes in compliance, etc. Additionally we have provided expected UDS findings based on neurogenic disease process, including but not limited to, Parkinson’s, dementia, multiple sclerosis (MS) and spinal cord injury based on lesion location. Pattern recognition and understanding of UDS can help lead to quality of life improvements and optimal management for the patient with neurogenic bladder dysfunction.