Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients

PURPOSE: Controversy continues on the optimal method of bladder management in spinal cord injured patients. We investigated the effects of bladder management on bladder compliance and changes in compliance with time. MATERIALS AND METHODS: We retrospectively reviewed the charts, and video urodynamic and upper tract radiographic studies of 316 patients with spinal cord injury. Patients were categorized according to interval since injury and bladder management method, including clean intermittent catheterization, spontaneous voiding and chronic Foley catheterization. Those with upper tract complications were compared with asymptomatic controls at the bladder compliance threshold values of 10.0, 12.5, 15.0 and 20.0 cc/cm. water. RESULTS: No significant differences were noted among bladder management method groups for followup, level, completeness or mechanism of injury. A bladder compliance threshold of 12.5 cc/cm. water was selected for the remaining comparisons based on the frequency of complications compared with asymptomatic controls. Patients using intermittent catheterization had a significantly higher incidence of normal compliance than the Foley management group for suprasacral, complete and incomplete injury (p<0.01). Normal bladder compliance was more common in patients with suprasacral than sacral and incomplete than complete spinal cord injury for each bladder management type. Logistic regression analysis of compliance versus bladder management and age of injury (interval since injury) revealed that intermittent catheterization and spontaneous voiding were associated more with normal compliance than Foley catheterization (RR = 9.2, 5.4 and 1.0, respectively). Combined data showed that each successively older age of injury cohort was at 23% greater risk for loss of normal compliance than the preceding cohort. Low compliance was statistically associated with vesicoureteral reflux, radiographic upper tract abnormality, pyelonephritis and upper tract stones (p<0.01, <0.01, 0.04 and <0.01, respectively). CONCLUSIONS: Clean intermittent catheterization protects bladder compliance in spinal cord injured patients regardless of the level or completeness of injury and helps to prevent low compliance with time. Also, in the population studied low compliance was associated with upper tract complications. Therefore, clean intermittent catheterization is the superior method for preserving bladder compliance and preventing the upper tract complications associated with low compliance.     

神经源性膀胱尿道功能障碍患者的影像尿动力学研究

目的 探讨各类神经源性膀胱患者的影像尿动力学特点.方法 2002年12月至2008年6月间,我们对1800例神经源性膀胱患者进行了影像尿动力学检查,分析不同神经病变所致膀胱尿道功能障碍的影像学特点.结果 脑卒中患者均未发现上尿路改变和反流,71% 为逼尿肌过度活动(DO),60% 伴括约肌无抑制性松弛,29% 为逼尿肌无反射(DA).脑外伤患者中70% 为DO不伴协同失调.7例帕金森病患者均表现为DO.1170例骶上损伤患者91% 为DO,83% 伴逼尿肌括约肌协同失调(DSD),223例骶髓及以下损伤患者73% 为DA.共有12% 的创伤性脊髓损伤患者出现上尿路积水改变,4% 表现为膀胱输尿管反流.脊髓发育不良患者81% 表现为逼尿肌无反射,86% 膀胱顺应性下降,55% 有上尿路积水改变,31% 出现膀胱输尿管反流.腰椎间盘突出患者92% 为逼尿肌无反射,88% 膀胱顺应性基本正常.糖尿病膀胱患者81% 膀胱感觉减退,76% 排尿期逼尿肌收缩力低下.结论 不同神经病变所致神经源性膀胱尿道功能障碍的特点不同,应根据影像尿动力学检查结果 选择合适的临床治疗方案.     

Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury

PURPOSE: To our knowledge risk factors for urinary tract infection associated with various drainage methods in patients with spinal cord injury have never been evaluated overall in the acute period. We identified the incidence and risk factors associated with urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: We prospectively followed 128 patients at our spinal cord injury reference hospital for 38 months and obtained certain data, including demographic characteristics, associated factors, methods of urinary drainage, bladder type, urological complications and predisposing factors of each infection episode. Logistic regression modeling was done to analyze variables and identify risk factors that predicted urinary tract infection. RESULTS: Of 128 patients 100 (78%) were male with a mean age plus or minus standard deviation of 32 +/- 14.52 years. All patients had a nonfatal condition by McCabe and Jackson guidelines, and 47% presented with associated factors. The incidence of urinary tract infection was expressed as number episodes per 100 patients daily or person-days. The overall incidence of urinary tract infection was 0.68, while for male indwelling, clean intermittent, condom and female suprapubic catheterization, and normal voiding the rate was 2.72, 0.41, 0.36, 0. 34 and 0.06, respectively. The risk factors associated with urinary tract infection were invasive procedures without antibiotic prophylaxis, cervical injury and chronic catheterization (odds ratio 2.62, 3 and 4, respectively). Risk factors associated with repeat infection were a functional independence measure score of less than 74 and vesicoureteral reflux (odds ratio 10 and 23, respectively). CONCLUSIONS: Spinal cord injured patients with complete dependence and vesicoureteral reflux are at highest risk for urinary tract infection.     

THE ROLE OF OXYBUTYNIN IN SPINAL CORD INJURED PATIENTS WITH INDWELLING CATHETERS

Purpose

The long-term benefits of oral oxybutynin in spinal cord injured patients with indwelling catheters is unknown. We reviewed our experience with this population of men and present the results of our analysis.

Materials and Methods

A total of 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Center have been treated with chronic indwelling catheters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Specifically examined were bladder compliance, bladder leak point pressure, vesicoureteral reflux, hydronephrosis, urolithiasis, febrile urinary tract infections and serum creatinine greater than 2 mg./dl.

Results

The mean duration of indwelling catheter use was 11.9 years (12.4 without oxybutynin and 10.9 on oral oxybutynin). Of the 31 patients with normal compliance (greater than 20 ml./cm. water), 24 (77%) were using oxybutynin (p = 0.001). Bladder leak point pressures were abnormal (greater than 35 cm. water) in 5 of 32 patients (16%) on oxybutynin versus 34 of 60 (57%) without it (p <0.001). Hydronephrosis was present in 15 of 66 patients (23%) without oxybutynin versus 1 of 36 (3%) with oxybutynin (p = 0.009). Febrile urinary tract infections occurred in 4 of 35 patients (11%) versus 17 of 62 patients (27%) with or without oxybutynin, respectively (p = 0.077). No significant differences were found between the 2 groups with regard to reflux, renal scars, stones or elevated serum creatinine.

Conclusions

It appears that regular use of oxybutynin may be beneficial in spinal cord injured patients who require chronic indwelling catheters for bladder management. Our analysis reveals that patients who take oxybutynin regularly have better bladder compliance, lower bladder leak point pressures and less hydronephrosis. Until a prospective, randomized trial reveals contradicting outcomes, empiric use of oxybutynin in all spinal cord injured patients requiring chronic indwelling catheters seems justified.     

脊髓栓系患者的尿动力学评估和治疗对策

目的　探讨脊髓栓系对膀胱尿道功能的影响。　方法　采用影像尿动力学检查评估36例脊髓栓系患者的膀胱尿道功能 ;以膀胱顺应性和有无膀胱输尿管返流评估膀胱的储尿功能 ;以排尿期逼尿肌压力评估逼尿肌排尿功能 ;结合膀胱尿道透视和尿动力学检查了解有无逼尿肌 外括约肌的协同性 ,并结合压力 流率曲线了解尿道的控尿功能。采用 χ2 检验比较各组参数异常发生的频数。　结果　脊髓栓系后神经源性膀胱的类型主要为逼尿肌反射不能伴低顺应性膀胱 ,占 5 0 % (18/36 ) ;逼尿肌反射亢进占 2 2 % (8/ 36 )。逼尿肌反射不能伴低顺应性膀胱者其肾功能损害的发生率83% (15 / 18) ,明显高于逼尿肌反射亢进者 (38% ,3/ 8,P <0 .0 5 )。膀胱顺应性减低者肾功能异常占81% (17/ 2 1) ,明显高于顺应性正常者 (7% ,1/ 15 ,P <0 .0 1)。顺应性减低者膀胱输尿管返流发生率6 7% (14 / 2 1) ,明显高于顺应性正常者 (7% ,1/ 15 ,P <0 .0 1)。　结论　脊髓栓系所致的神经源性膀胱类型各异 ,治疗方案的制定应以尿动力学结果为依据。顺应性减低可能是造成肾功能损害和膀胱输尿管返流的主要原因 ,泌尿外科治疗目的在于创建一低压、足够容量和控尿的膀胱以保护上尿路功能     

Epididymo-orchitis risk factors in traumatic spinal cord injured patients

STUDY DESIGN: Retrospective audit and interview-based study of a traumatic spinal cord injured cohort, assessing the incidence and risk of epididymo-orchitis (E-O). OBJECTIVES: Assess the potential risk factors for E-O in this cohort (spinal cord injured patients). SETTING: Janbazan Clinic for Spinal Cord Injuries, Mashad, Iran. METHODS: A retrospective notes audit of 169 male traumatic spinal cord injured (SCI) patients was performed. In addition, interviews were performed to confirm any equivocal data. The following risk factors were assessed: history of recurrent urinary tract infections (UTIs), urethral stricture, urethral diverticuli, urinary fistula, urinary calculi, spinal injury type, neurogenic bladder type, autonomic dysreflexia, vesico-ureteral reflux, sphincterotomy, vasectomy, marriage status, bladder residual and emptying method, ejaculation, spinal injury level, micturation control, and muscular spasm, which included detrusor, external sphincter or lower limb spasm. RESULTS: A total of 65 patients from our group (38.5%) had suffered E-O at least once. E-O presented on average, 3.9 years after the SCI. Patients with a history of muscular spasm appeared less likely to develop E-O (P<0.05). None of the vasectomised patients developed E-O. The relation between all the other factors and E-O were not significant. CONCLUSIONS: Our study has shown that the presence of muscular spasm decreases the risk of E-O, although the mechanism remains unclear. Surprisingly, the other historical risk factors showed no clear relation with E-O occurrence.     

An attempt to understand and to treat voiding dysfunctions during rehabilitation of the bladder in spinal cord injury patients.

An attempt to understand and treat dysfunctions during bladder rehabilitation in 150 spinal cord injury patients is presented. The 25 problem patients were further analyzed to identify and manage the dysfunctional bladder and bladder neck, dyssenergic pelvic floor, vesicoureteral reflux, areflexic detrusor muscle and also to discontinue prolonged intermittent catheterization. The initial excellent results with a modified approach to sphincterotomy and the bladder neck operation in 15 patients are presented. Early recognition of patients in whom intermittent catheterization may not be successful will allow one to intervene and establish an early catheter-free status. A new concept of the existence of receptors in the posterior urethra has been postulated.     

The timing of primary neurosurgical repair significantly affects neurogenic bladder prognosis in children with myelomeningocele

PURPOSE: The correlation between timing of the primary neurosurgical repair and urological prognosis in infants with open spinal dysraphism remains unknown. We investigated the impact of primary repair timing on neurogenic bladder prognosis in children with myelomeningocele. MATERIALS AND METHODS: We retrospectively reviewed the records of 401 children with myelomeningocele followed at our multidisciplinary clinic between 1996 and 2005. Among these patients 129 were included in the study based on the availability of urological followup data at age 3 years, which was chosen as an ideal point for the standardization of urological findings. Children were assigned to 1 of 2 groups-those who underwent primary neurosurgical repair within 72 hours of delivery (group 1) and those undergoing repair after 72 hours (group 2). We compared the incidence of febrile urinary tract infections, hydronephrosis, vesicoureteral reflux and secondary tethering of the spinal cord at age 3 years, as well as cystometric bladder capacity and detrusor leak point pressure between the 2 groups. RESULTS: Urological followup data at age 3 years revealed significantly increased incidence of febrile urinary tract infections, vesicoureteral reflux, hydronephrosis and secondary tethering of the spinal cord in children in group 2 compared to group 1 (chi-square, p < or =0.05 for all comparisons). Urodynamic assessment also showed a significantly lower bladder capacity and a substantially higher detrusor leak point pressure in children who received primary repair at later than 72 hours (t test, p <0.05). A subgroup analysis of group 1 comparing children who underwent repair before and after 24 hours following delivery failed to demonstrate any significant difference in terms of febrile urinary tract infections, vesicoureteral reflux, hydronephrosis and secondary tethering (chi-square, p >0.05 for all comparisons), whereas mean bladder capacity was significantly higher (t test, p <0.05) and mean detrusor leak point pressure was lower (t test, p = 0.08) in children undergoing repair within 24 hours of delivery. CONCLUSIONS: The timing of primary neurosurgical repair has a significant impact on neurogenic bladder prognosis in children with myelomeningocele. Closure of the spinal lesion on the first day of life seems to provide the best chance for favorable lower urinary tract function.     

Cancer of the bladder in a patient with spinal cord injury

A case of cancer of urinary bladder in a 39-year-old incomplete C7 paraplegic male is reported. He was injured in 1962, and was admitted to our department in August, 1982 because of macrohematuria. Intravenous pyelography showed dilation of right ureter and pelvis. Cystography revealed filling defect on the right wall of bladder, but vesicoureteral reflux was not seen. Endoscopically, we found the tumor on the right wall, which seemed to invade to the trigone and right ureteral orifice. CT scan and pelvic angiography showed that the tumor extended extramurally of the bladder and metastasized to lymph-nodes. In November, 1982, bilateral ureterocutaneostomy, and 30 days later, total cystectomy were performed. The removed bladder demonstrated transitional cell carcinoma with undifferentiated tumor cells. The patient died of recurrence of the tumor in the small pelvic cavity, 60 days later. Ten cases of bladder cancer in patients with spinal cord injury were collected from Japanese literature including ours, and the importance of periodic cytology, cystoscopy and random biopsy for early diagnosis of bladder cancer on paraplegics were discussed.     

Urodynamic Correlates of Resolution of Reflux in Meningomyelocele Patients

Purpose

Resolution of reflux in meningomyelocele patients is a reflection of improved bladder storage. We correlated resolution of reflux with changes observed in sequential urodynamic studies.

Materials and Methods

The study included 27 children with meningomyelocele born between 1975 and 1985 who presented with or developed vesicoureteral reflux. Resolution of reflux was observed during the 10-year followup period as they were treated with a regimen of clean intermittent catheterization and pharmaco-therapy. Urodynamic studies were performed when vesicoureteral reflux was present and subsequent to its resolution. The urodynamic parameters compared in the 2 studies included bladder capacity, pressure specific bladder volume, bladder compliance and leak point pressure.

Results

Significant increases in bladder capacity, pressure specific bladder volume and bladder compliance were noted. Leak point pressure appeared to be decreased subsequent to resolution of reflux.

Conclusions

Resolution of reflux in meningomyelocele patients correlates with changes in parameters of bladder storage observed on sequential urodynamic studies.     

Influences on renal function in chronic spinal cord injured patients

PURPOSE: The optimal method of bladder management in the spinal cord injured population remains controversial. We determined the significance of bladder management and other factors on renal function in this population. MATERIALS AND METHODS: We retrospectively reviewed the medical records and upper tract imaging studies of 308 patients with a mean followup of 18.7 years since injury. Renal function was assessed by serum creatinine, creatinine clearance and proteinuria measurement, and by upper tract abnormalities on renal ultrasound and nuclear medicine renal scan. Independent variables evaluated for an influence on renal function included patient age, interval since injury, injury level and completeness, vesicoureteral reflux, history of diabetes mellitus and bladder management method. RESULTS: Mean serum creatinine plus or minus standard deviation in patients on chronic Foley catheterization, clean intermittent catheterization and spontaneous voiding was 1.08 +/- 0.99, 0.84 +/- 0.23 and 0.97 +/- 0.45 mg./dl. (analysis of variance p = 0.05, Student's t test p = 0.10), and mean creatinine clearance was 91.1 +/- 46.5, 113.4 +/- 39.8 and 115 +/- 49 ml. per minute, respectively (analysis of variance and Student's t test p <0.01), respectively. Proteinuria was present in 19 patients (6.2%) in the Foley catheterization, 3 (1%) in the clean intermittent catheterization and 4 (1.3%) in the spontaneous voiding group (chi-square test p <0.01), while there were upper tract abnormalities in 56 (18.2%), 20 (6.5%) and 24 (7.8%) patients, respectively (chi-square test p <0.01). Multiple regression analyses revealed no significant predictors of serum creatinine, although older patient age and Foley catheterization significantly predicted low creatinine clearance. Additional logistic regression analyses showed that Foley catheterization was associated with proteinuria and vesicoureteral reflux was associated with upper tract abnormalities. CONCLUSIONS: While renal function may be preserved by all forms of bladder management, chronic indwelling catheters may contribute to renal deterioration.     

The effects of botulinum-A toxin on bladder function and histology in spinal cord injured rats: is there any difference between early and late application?

PURPOSE: We explored the effects of early and late application of botulinum-A toxin (BTX-A) on reservoir function and histological bladder changes in spinal cord injured rats. MATERIALS AND METHODS: The study was done in 30 Sprague-Dawley rats randomly allocated into 5 groups. Group 1 of 6 rats underwent sham operation only. Group 2 of 6 rats underwent spinal cord transection. Group 3 of 6 rats underwent spinal cord transection followed by BTX-A application into the detrusor muscle 7 days later. Group 4 of 6 rats underwent spinal cord transection, followed by BTX-A application into the detrusor muscle 28 days later. Group 5 of 6 rats underwent spinal cord transection followed by saline injection into the detrusor muscle after 28 days. Spinal cord injury was created by transecting the cord at the T9 to T10 level. All rats underwent cystometric examination initially and on day 42 before sacrifice. The bladders were removed and examined histologically for fibrosis and hyperplasia. RESULTS: On cystometric examination BTX-A caused an improvement in baseline pressure, and the frequency and amplitude of uninhibited detrusor contractions (p <0.001). No significant differences were observed in maximal bladder capacity or urethral opening pressure (p >0.05). Histologically BTX-A led to decreased fibrosis and hyperplasia (p <0.001). No significant differences were found between histological or cystometric among the groups with respect to receiving BTX-A in the early and late periods (p >0.05). CONCLUSIONS: BTX-A has a functional and histological healing effect on detrusor hyperreflexia subsequent to spinal cord injury in rats. Although administering BTX-A in the early period had better quantifiable functional and histological outcomes compared to the late period, the difference was not statistically significant.     

Augmentation ileocystoplasty in patients with neurogenic bladder due to spinal cord injury or spina bifida

STUDY DESIGN: Retrospective analysis of augmentation ileocystoplasty for neurogenic bladder. OBJECTIVES: To analyze the effects and complications of augmentation ileocystoplasty in patients with neurogenic bladder due to spinal cord injury (SCI) or spina bifida retrospectively. SETTING: Department of Urology, Kanagawa Rehabilitation Hospital, Japan. METHODS: We have treated 11 patients with neurogenic bladder due to SCI and 10 patients with spinal bifida with augmentation ileocystoplasty since 1989. The purpose of the treatment was to stop vesicoureteral reflux (VUR) and/or amelioration of urinary incontinence. In 17 of 21 cases, the antireflux operation was received simultaneously. All cases performed clean intermittent self catheterization postoperatively. RESULTS: Urinary incontinence improved in all cases and only transient recurrence of VUR was observed in the follow-up term. Complications occurred in patients with SCI, but they could be treated conservatively. CONCLUSION: Augmentation ileocystoplasty is a good treatment option for contracted bladder or VUR, which occurs in patients with neurogenic bladder.     

Urological aspects of the tethered cord syndrome

We performed urological evaluations in 18 patients with the tethered spinal cord syndrome. Of the patients 4 had low grade vesicoureteral reflux but none had significant upper tract anomalies. Urodynamic studies documented a flaccid bladder in 9 patients (5 with supersensitivity to bethanechol), an uninhibited bladder in 5, mixed bladder dysfunction in 2 and normal function in 2. Repeat urodynamic studies were performed in 15 patients at least 6 months after release of the tethering. Of 8 patients with flaccid bladders studied postoperatively 6 had significant changes: 2 became normal, 2 had limited contractions and 2 had evidence of upper motor neuron abnormalities. Supersensitivity to bethanechol was of no predictive value. All 4 patients with uninhibited bladders who were evaluated preoperatively and postoperatively had improved and 3 currently are entirely normal. Careful urological evaluation of patients with the tethered spinal cord syndrome is helpful not only for diagnosis but also for appropriate management preoperatively and postoperatively. The fact that lower urinary tract function improves in some patients should encourage early and aggressive neurosurgical management of patients with this syndrome.     

Migration and distribution of bone marrow stromal cells in injured spinal cord with different transplantation techniques

Objective： To study the regularity of migration and distribution of bone marrow stromal cells （BMSCs） in injured spinal cord with intradural space transplantation. Methods： Forty Wistar rats were randomly assigned into 4 groups. The spinal cord injury model was prepared according to the modified Allen method. BMSCs were labeled by CM-Dil. And 5.0x 10^6 cells were transplanted by different channels including intraventricular injection （Group A）,injured spinal cord intrathecally injection （Group B）, remote intrathecally injection at the L3-L4 level （Group C）, and intravenous injection （Group D）. Spinal cord was dissected at 24 hours, 1, 2, 3 and 4 weeks after transplantation. Sections of 4 μm were cut on a cryostat and observed under fluorescence microscopy. Results： No fluorescence was observed 24 hours aftertransplantation in spinal cord injury parenchyma except Group B. One week later, BMSCs in Groups A and C began to migrate to the injured parenchyma; 2-4 weeks later, BMSCs penetrated into the injured parenchyma except Group D. The number of BMSCs decreased at 3-4 weeks after transplantation. The number of cells in Group B decreased faster than that of Groups A and C. Conclusions： BMSCs transplanted through intraventricular injection, injured spinal cord intrathecally injection and remote intrathecal injection could migrate to the injured parenchyma of spinal cord effectively. The number of BMSCs migrated into injured spinal cord parenchyma is rare by intravenous injection.     

Does the type of bladder augmentation influence the resolution of pre‐existing vesicoureteral reflux? Urodynamic studies

AIMS: The type of bladder augmentation on pre-existing vesicoureteral reflux (VUR) was assessed. The effects of urodynamic changes on the resolution of VUR following augmentation cystoplasty performed with various gastrointestinal segments were examined. It was queried whether elimination of high-pressure bladder is sufficient to resolve pre-existing reflux. METHODS: A retrospective record review of patients who underwent bladder augmentation between 1987 and 2004. Patients were divided into two groups. Group I included patients who had a simultaneous augmentation and ureteral reimplantation. Group II included patients with reflux in whom only a bladder augmentation was performed. Pre-and post-augmentation urodynamic results were compared in both groups. The outcome of VUR and the role of various gastrointestinal (GI) segments on the resolution of VUR were studied. RESULTS: Sixty-three patients underwent bladder augmentation during the study period. Twenty-six of them had VUR before augmentation. There were 10 patients in Group I and 16 patients in Group II. In Group I, VUR ceased in all patients, while in group II, VUR resolved in 14 patients and persisted in two patients. Small and large bowel segments used for augmentation had no effect on the resolution of VUR but the results of gastrocystoplasties were less favorable. Urodynamically there was no significant difference between the various augmentation cystoplasties. CONCLUSIONS: Bladder augmentation alone without simultaneous antireflux repair is usually sufficient for the resolution of pre-existing reflux. The various GI segments used for augmentation have no effect on urodynamic results and the resolution of VUR.     

The role of abnormal congenitally displaced ureteral orifices in causing reflux following spinal cord injury

OBJECTIVE: To determine the role of congenitally displaced ureteral orifices in causing vesicoureteral reflux (VUR) in individuals with spinal cord injury (SCI). DESIGN: Retrospective chart review. PARTICIPANTS: Men and women with (UMN) neurogenic bladders secondary to SCI. MAIN OUTCOME MEASURES: Position of the ureteral orifice and urodynamic parameters in association with VUR. METHODS: A retrospective chart review was performed to identify SCI participants with and without reflux who had evaluation with cystoscopy, cystogram, and urodynamics. The position of ureteral orifice was compared in individuals with SCI who did and did not have ureteral reflex. All cystogram studies were interpreted by board-certified radiologists. The International Classification system was used to grade the severity of the reflux. Fisher exact test was used to evaluate the association of the posterior ureteral orifice and reflux. Analysis also was performed to evaluate the association of reflux with posterior-placed ureteral orifices and urodynamic parameters in the reflux group and nonreflux group. RESULTS: Fifteen participants were found to have reflux--11 had posterior-placed ureteral orifices, whereas 4 had normally positioned orifices. The 11 individuals with posterior-placed ureteral orifices had no bladder wall trabeculation. However, all 4 individuals with normally positioned ureteral orifices had severe trabeculation. Seventeen participants did not exhibit reflux--2 had posteriorly placed ureteral orifices and 15 had normally positioned orifices. Association of posterior position and reflux (P = 0.004). No differences were found with regard to bladder capacity, bladder wall compliance, or voiding pressures between the reflux group and nonreflux group. CONCLUSION: Congenitally displaced ureteral orifices are an important cause of VUR in individuals with SCI. Participants with normally positioned ureteral orifices only had reflux in the presence of severe trabeculation. This study suggests that annual screening with cystograms may not be necessary in individuals with normally positioned ureteral orifices and no significant trabeculation.     

脊髓损伤排尿功能障碍患者的尿动力学分析

目的 了解不同节段脊髓损伤后膀胱尿道功能障碍的差异.方法 回顾性分析30例脊髓损伤患者的尿动力学资料.男22例,女8例.年龄17～74岁,平均47岁.病程7～36个月,平均18个月.其中胸腰段脊髓损伤19例,骶髓损伤11例.2组尿动力检查结果行单因素方差分析或秩和检验比较.结果 胸腰段脊髓损伤组与骶髓损伤组自由尿流率参数比较:最大自由尿流率(13.0±5.1)与(13.0±5.8)ml/s,2 s时自由尿流率(6.5±5.1)与(6.9±6.4)ml/s,平均自由尿流率(5.4±2.4)与(3.4±0.5)ml/s,自主排尿量(279.1±131.1)与(450.0±26.6)ml,残余尿量(209.5±180.7)与(434.0±215.0)ml;2组排尿量和残余尿量比较差异有统计学意义(P＜0.05).2组完全性膀胱测压参数比较:最大尿流率(16.0±23.3)与(7.1±3.3)ml/s,平均尿流率(4.6±2.3)与(3.9±2.3)ml/s,排尿后2 s的尿流率(4.6±3.1)与(2.2±3.2)ml/s,排尿量(268.4±113.9)与(129.0±97.9)ml,最大尿流率时的逼尿肌压力(58.8±22.0)与(56.5±14.5)cm H2O(1 cm H2O=0.098 kPa),逼尿肌最大压力时的尿流率(4.8±2.0)与(4.8±4.4)ml/s,逼尿肌最大压力(68.0±31.0)与(54.6±20.2)cm H2O,排尿期平均压力(47.4±20.0)与(42.6±13.9)cm H2O,2组排尿量比较差异有统计学意义(P＜0.05).2组膀胱感觉及膀胱尿道协同性差异无统计学意义(P＞0.05),胸腰段损伤患者中低顺应性膀胱(4/11)发生率较高,骶髓损伤患者中高顺应性膀胱(11/19)发生率较高.结论 骶髓损伤和胸腰段脊髓损伤患者区别主要为膀胱顺应性的差异和膀胱逼尿肌收缩能力的改变,骶髓损伤患者逼尿肌收缩能力降低、高顺应性膀胱发生率较高,胸腰段脊髓损伤患者逼尿肌收缩亢进、低顺应性膀胱发生率较高.

Abstract：

Objective To find the differences of bladder and urethra dysfunction between sacral spinal cord injury and Thoracolumbar spinal cord injury.Methods According to the criteria of inclusion and exclusion, we collected 30 patients in the study group.There were 22 males and 8 females, aged 17 -74 ( mean, 47 ) years, with duration between 7 - 36 ( mean, 18) months.There were nineteen cases of thoracolumbar spinal cord injury and 11 cases of sacral spinal cord injury in the study group.We conducted a retrospective analysis of the urodynamic data of the 30 patients in the group.They were divided into a sacral spinal cord injury group and a thoracolumbar spinal cord injury group according to the location of the site of injury.The urodynamic findings of the two groups were comparable.SPSS 16.0 was used to compare the differences between the groups by ANOVA/rank sum test.Results We measured the free flow rate parameters between thoracolumbar and sacral spinal cord injury groups.The maximum free flow rate was ( 13.0 ±5.1 ) vs ( 13.0 ±5.8) ml/s, the free flow rate at 2 s was (6.5 ±5.1 ) vs (6.9 ±6.4) ml/s, the mean free flow rate was (5.4± 2.4) vs ( 3.4 ± 0.5 ) ml/s, urine output volume was ( 279.1 ±131.1 ) vs (450.0 ± 26.6) ml and the residual urine volume was (209.5 ± 180.7 ) vs (434.0 ± 215.0) ml.The residual urine volume and urine output volume of sacral the spinal cord injury group was higher than the thoracic spinal cord injury group (P ＜ 0.05).We also measured the the cystometric parameters.The maximum urinary flow rate was (16.0±23.3) vs (7.1 ±3.3) ml/s, average flow rate was (4.6 ±2.3) vs (3.9 ± 2.3) ml/s, the flow rate after voiding 2 s was (4.6 ± 3.1 ) vs (2.2 ± 3.2) ml/s, urine output volume was (268.4 ± 113.9) vs ( 129.0 ± 97.9) ml, detrusor pressure of maximum flow rate was (58.8 ± 22.0) vs (56.5 ± 14.5) cm H2 O, flow rate of maximum detrusor pressure was (4.8 ± 2.0) vs (4.8 ± 4.4) ml/s,the maximum detrusor pressure was (68.0 ± 31.0) vs (54.6 ± 20.2) cm H2O and the average pressure of voiding period was (47.4 ±20.0) vs (42.6 ± 13.9) cm H2O.The urine output volume of the thoracolumbar spinal cord injury group was lower than sacral spinal cord injury group ( P ＜ 0.05 ).There were no significant differences in bladder sensation and coordination of bladder/urethra between the thoracolumbar spinal cord injury group and the sacral spinal cord injury group (P ＞ 0.05).The incidence of low compliance bladder in the thoracolumbar spinal cord injury patients (4/11) was higher than the sacral spinal injury group, the incidence of high compliance bladder in the sacral spinal cord injury patients (11/19) was higherthan the thoracolumbar group.Conclusions The urodynamics' difference between the sacral spinal cord injury group and thoracolumbar spinal cord injury group was observed in bladder compliance and bladder detrusor contractility changes.Relatively, the incidence of decreased detrusor contractility and high compliance bladder in sacral spinal cord injury patients was higher, and the cidence of detrusor hyperreflexia and low compliance bladder in thoracolumbar spinal cord injury patients was higher.     

The impact of contemporary bladder management techniques on struvite calculi associated with spinal cord injury.

OBJECTIVE: To evaluate the incidence, risk factors and complications of upper tract struvite calculi, often associated with spinal cord injury (SCI), as such patients have a high incidence of urinary infection complicating their neurogenic voiding dysfunction, by reviewing a large population of patients with SCI in whom modern techniques of bladder management were used. PATIENTS AND METHODS: Between 1982 and 1996, 1669 patients with SCI were admitted to our institution; 1359 of these patients sustained their injuries during the study period. During this time, their bladder management was based on urodynamic and imaging criteria, using techniques such as early intermittent catheterization, sphincterotomy and bladder augmentation where possible to create a catheter-free, low-pressure reservoir. All instances of upper tract struvite calculi in this population were documented. Risk factors for stone development, presentation and complications, management and recurrence rates were assessed. RESULTS: Over the 15 years, 58 patients (3.5% of the SCI population) were treated for a total of 144 episodes of struvite calculi. The incidence of stones in those injured since 1982 was 1. 5%; 67% of these patients had complete spinal cord lesions, 54% had lesions of the cervical cord and 53% developed their first stone >10 years after injury. Only 22% presented within 2 years of injury. The group of patients developing stones had a significantly higher incidence of indwelling catheters (49%), bladder stones (52%) and vesico-ureteric reflux (28%) than those who were stone-free. The development of recurrent urinary tract infections was the most common mode of presentation. The stone-free rate after treatment was 87%. Normal renal function was preserved in 72% of patients. CONCLUSIONS: In a large population of patients with SCI managed using contemporary bladder techniques the incidence of upper tract calculi was 3.5%; 30% of these stones were complete or partial staghorns. Those patients with complete cord lesions, permanent indwelling catheters and vesico-ureteric reflux were at the highest risk. Stone clearance was 87% and recurrent stones occurred in 69% of patients. Struvite renal calculi continue to be a significant problem in the spinal cord injury population.     

Bladder neck incompetence in patients with spinal cord injury: significance of sympathetic skin response

PURPOSE: We investigated whether recording the perineal sympathetic skin response, which reflects the sympathetic function of the thoracolumbar spinal cord, represents a reliable and accurate diagnostic tool for assessing bladder neck competence and incompetence. MATERIALS AND METHODS: We compared the sympathetic skin response recorded from the hand, foot and perineal skin with urodynamic findings in 90 patients with neurogenic bladder dysfunction, including 66 with spinal cord injury and 24 with cauda equina lesions. RESULTS: Video urodynamics revealed an incompetent bladder neck in 11 of 32 patients (34%) with complete and 7 of 34 (21%) with incomplete spinal cord injury but in only 1 of 24 (4%) with the conus-cauda equina syndrome. This association significantly correlated with the lesion level at T10 to L2 in 12 of 26 cases (46%) as well as with the loss of perineal but preserved hand and foot sympathetic skin response in 13 of 18 (72%). CONCLUSIONS: Recording the perineal sympathetic skin response in addition to that of the hand and foot represents a sensitive diagnostic tool for assessing sympathetic nerve function within the thoracolumbar spinal cord. It is of diagnostic value for evaluating neurogenic bladder neck incompetence in spinal cord injured patients.