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.     

Effect of spinal cord abnormalities on the function of the lower urinary tract in patients with anorectal abnormalities

PURPOSE: We evaluated the effect of spinal cord abnormalities on lower urinary tract function in patients with anorectal abnormalities. MATERIALS AND METHODS: We examined 30 patients with anorectal anomalies mainly because of fecal or urinary incontinence. All patients underwent spinal magnetic resonance imaging and urodynamic investigation. RESULTS: Major lumbosacral abnormalities were detected in 57% of patients, including 13, 4 and 3 with a tethered cord, syringomyelia and caudal regression, respectively. Significant dysfunction of the lower urinary tract in 57% of the cases involved an overactive detrusor in 11, detrusor-sphincter dyssynergia in 4, distended bladder in 4 and lazy bladder in 1. When the spinal cord was normal, 54% of the patients had abnormal urodynamic findings but when the spinal cord was abnormal, 59% had abnormal urodynamics. When the bony spine was normal, 33% of the patients had an abnormal spinal cord but when the bony spine was abnormal, 69% had an abnormal spinal cord. CONCLUSIONS: Patients with anorectal abnormalities and fecal or urinary incontinence problems often have an abnormal spinal cord and abnormal urodynamic findings. However, the state of the spinal cord is not the only factor explaining lower urinary tract function. Thus, the possibility of lower urinary tract dysfunction should be considered in each patient with anorectal abnormalities. If the patient has symptoms or findings suggesting abnormal lower urinary tract function urodynamic evaluation should be performed.     

Effect of Oral Ciprofloxacin on Bacterial Flora of Perineum,Urethra, and Lower Urinary Tract in Men with Spinal Cord Injury

Abstract

A study was performed in 25 men with spinal cord injuries undergoing intermittent catheterization whose urine had > 1Cf’ bacterial colonies/ml to determine efficacy of ciprofloxacin in eradicating susceptible organisms from urine, urethra, and perineum. Cultures were obtained prior to, during, and 5 to 7 days after administration of 500 mg twice daily for 10 days. Organisms in urine were also present in the urethra and/or perineum in 20 cases. Susceptible bacteria disappeared from urine in all subjects; but at follow-up 12 had cultures positive for ciprofloxacin-resistant Gram-positive cocci, including 1 with methicillin-resistant Staphylococcus aureus (MRSA), and 2 with ciprofloxacin-resistant Acinetobacter sp. Treatment significantly reduced Gram-negative bacilli in perinea and urethras, but ciprofloxacin-susceptible organisms were replaced by resistant staphylococci, including MRSA, enterococci, and Acinetobacter sp. We support use of ciprofloxacin for treatment of urinary tract infections in persons with spinal cord injury, but in view of supercolonization with resistant organisms, the drug should be reserved for symptomatic persons not likely to respond to other oral agents.     

脊髓损伤患者上尿路损伤风险预测的膀胱内压临界值研究

目的探讨对脊髓损伤患者预测上尿路损伤风险的膀胱内压临界值。方法回顾性分析97例脊髓损伤患者的病历资料,根据诊断标准分为上尿路功能损害组和无上尿路功能损害组,比较两组的基线资料,进行膀胱内压诊断上尿路损伤的ROC曲线分析。结果上尿路损伤组年龄显著大于无上尿路损伤组,病程显著短于无上尿路损伤组(均P0.01),根据ROC曲线计算得到膀胱内压最佳临界值为33.25cmH2O。结论可将33.25cmH2O作为预测上尿路损伤的膀胱内压力临界值。     

Urodynamics in spinal cord injured patients walking with reciprocating gait orthosis

PURPOSE: We evaluated the effects of walking with reciprocating gait orthosis on bladder function and upper urinary tract status in spinal cord injured patients. MATERIALS AND METHODS: Seven patients using reciprocating gait orthosis underwent urodynamics before and during walking. Abdominal ultrasound was performed before and after urodynamics. RESULTS: Baseline urodynamics showed detrusor areflexia in 3 patients and hyperreflexia in 4. During walking urodynamics revealed hyperreflexia in 6 patients with worse uninhibited detrusor contraction amplitude (38.2 +/- 41.2 versus 73.7 +/- 44.4 cm. water, p = 0.006) and duration (2.1 +/- 2.1 versus 6.8 +/- 5.3 minutes, p = 0.023). After walking ultrasound demonstrated bilateral pyelectasia in 2 patients. CONCLUSIONS: Spinal cord injured patients using reciprocating gait orthosis have worse urodynamic measurements and upper urinary tract disorders during walking. They require close urological followup.     

A prospective study on acute spinal injuries

This work examines demographic and clinical characteristics of 163 consecutive cases of acute spinal injuries in a small area of Western Turkey, since 1982. These include all spinal injuries with or without neurological symptoms. Combined conservative and surgical methods were used for treatment. Age, sex, etiology, site of injury, radiologic findings, neurological status, and outcome are compared with the other studies. The results have been found to be parallel to those of the other studies except for some regional differences like an excess of tractor accidents.     

Video urodynamic findings in men with the central cord syndrome

PURPOSE: The central cord syndrome reportedly has a favorable prognosis and rehabilitation outcome. However, to our knowledge the status of the lower urinary tract in patients with the central cord syndrome is unclear. We report on 22 men with the central cord syndrome who were evaluated by video urodynamics. MATERIALS AND METHODS: From 1986 to the present we identified 22 men with a mean age of 51 years who had the central cord syndrome and were included in the Houston Veterans Affairs spinal cord registry. All patients underwent video urodynamic evaluation a mean of 34.5 months after injury. RESULTS: Video urodynamic testing for vesicourethral dysfunction was normal in 3 patients, while it showed bladder outlet obstruction secondary to benign prostatic hyperplasia in 2, detrusor areflexia in 4, external detrusor-sphincter dyssynergia in 11, detrusor hyperreflexia with a synergistic external urethral sphincter in 1 and detrusor hypocontractility in 1. Urinary tract infection recurred in 3 patients with external detrusor-sphincter dyssynergia and urolithiasis developed in 2. CONCLUSIONS: Urodynamic testing revealed a high incidence of external detrusor-sphincter dyssynergia in men with the central cord syndrome. Due to the potential for upper tract deterioration all patients with the central cord syndrome should undergo baseline urodynamic studies. Those at high risk for upper tract deterioration with external detrusor-sphincter dyssynergia or a loss of compliance should be treated more aggressively with clean intermittent catheterization and anticholinergic medication when possible.     

脊髓损伤后膀胱传人神经元特性的适应性改变

下尿路的储尿和周期性的排尿功能依赖于大脑、脊髓和外周神经节的神经通路。脊髓在腰骶段的损伤能够消除自主和脊上神经对于排尿的控制,产生逼尿肌和括约肌的失协调。脊髓损伤后下尿路的功能障碍部分取决于膀胱传入神经通路的适应性改变。本文综述了脊髓损伤后膀胱传入神经元在免疫组织化学、电生理学及受体表达等方面的改变。     

Bladder Management in Patients With Pediatric Onset Neurogenic Bladders

Abstract

Our objective was to determine which clean intermittent catheterization (CIC) methods and supplies were used by patients with pediatric onset neurogenic bladders and to relate methodology and materials to reported urinary tract infections. Data were collected via questionnaires distributed by mail and at clinic visits at our university tertiary care outpatient pediatric rehabilitation clinic. Questionnaires were given to 165 patients. Fifty-nine percent were returned (68 patients with myelomeningocele, 27 with pediatric onset spinal cord injury (SCI) and two with other diagnoses). Mean age was 12 years (range 1-27). Fifty-four percent of patients participated in their own CIC. Only two percent used sterile catheterization technique, whereas 98 percent used CIC. A sterile catheter was employed with clean technique by 22 percent. Catheters were reused by 76 percent. Subjects used a wide ranging number of catheters per month, with a median of 5.3. There was no correlation between the number of urinary tract infections (UTIs) per year and the type of catheter used or the use of prophylactic antibiotics. Compared with patients with myelomeningocele, subjects with SCI were significantly more likely to use sterile catheters (p=0.04), >10 catheters per month (p=0.01) and gloves (p<0.001). Subjects who used gloves or more catheters were more likely to experience UTI. These data suggest that clean reused supplies are not related to an increased likelihood of UTI and should be considered a way to lower costs in these populations. (J Spinal Cord Med 1997;20:410-415)     

Urethral evoked sympathetic skin responses and viscerosensory evoked potentials as diagnostic tools to evaluate urogenital autonomic afferent innervation in spinal cord injured patients

PURPOSE: In most spinal cord injured (SCI) patients the objective assessment of afferent neuronal pathways from the lower urinary tract and the recording of a disturbed urethral sensation and/or desire to void are still difficult. Viscerosensory evoked potentials (VSEPs) might be helpful, but they remain technically difficult to obtain and interpretation is delicate. As a new approach, sympathetic skin response (SSR) of the hand and foot were recorded after electrical stimulation of the posterior urethral mucosa. This technique should allow assessment of the integrity or deterioration of the autonomic afferent pathway. MATERIALS AND METHODS: A total of 20 males and 8 females with SCI somatosensory incomplete 15, somatosensory complete 13 and 6 healthy male volunteers were prospectively examined. During urodynamic examination electrical stimulation (single square pulses of 0.2 ms, 2 to 3-fold sensory threshold, 60 mA in complete SCI patients) of the posterior urethra/bladder neck was performed using a bipolar electrode inserted into a microtip pressure catheter. SSR recordings of the right palm and sole were simultaneously taken using surface electrodes and were analyzed by an electromyography unit. Patient reports on evoked urethral sensations at individual sensory thresholds were simultaneously noted. Additionally, well-known electrophysiological measurements such as pudendal sensory evoked potential and urethral VSEP were recorded to check clinical assessed somatosensory and viscerosensory status, and to compare SSR results with these conventional methods. RESULTS: Electrical stimulation of the posterior urethra evoked clear urethral sensation and SSRs in normal subjects. In 14 of 15 sensory incomplete SCI patients with disturbed urethral sensation SSRs could be recorded as well. Electrically evoked urethral sensations resembled the subjective desire to void at full bladder reported by controls and patients. In 13 sensory complete SCI patients with loss of any urethral sensation SSRs could not be recorded even at maximal electrical stimulation strength. All subjects with electrically induced urethral sensation had positive evoked (supralesional) SSRs of the hand. However, none of the patients with absent urethral sensation presented SSRs. Simultaneously recorded VSEPs could not be recorded clearly in 5 patients and 2 control subjects, whereas SSRs delivered clear results in all controls and patients, matching their reports. CONCLUSIONS: SSR recordings above a spinal lesion level after urethral electrostimulation might provide a useful and technically simple objective diagnostic tool to assess integrity of autonomic (visceral) afferent nerves from the lower urinary tract. Somatosensory deficits are not always paralleled by viscerosensory loss and vice versa. In this study SSRs were superior to VSEPs, the latter being more difficult to record. The subjective sensations reported by subjects during stimulation could be confirmed in an objective way in 100% of cases by positive/negative SSR findings.     

Decreased Incidence of Urinary Tract Infections in Patients with Spinal Cord Injury: Effect of Methenamine

ABSTRACT

This study was designed to determine the effect of methenamine on the frequency of urinary tract infections (UTI) in hospitalized patients after spinal cord injury. The study included 56 patients with neurogenic bladder dysfunction treated with intermittent catheterization. A group of 34 patients was treated with methenamine, 1g twice daily; the other group of 22 patients was the control group receiving no antimicrobial therapy. On a weekly basis urine samples from all patients were obtained for urinalysis and culture. A total of 500 urine samples were analyzed. The patients treated with methenamine had 23.4% positive urine cultures which was significantly lower than 57.5% in the untreated control group (p<0.001). Our data suggest that methenamine therapy is an effective prevention of UTI in paralyzed patients with neurogenic bladder dysfunction during the rehabilitation in hospital. (J Am Paraplegia Soc 1991; 14: 52–54)