Neurogenic Bladder: Past,Present, and Future

Abstract

Summary: The foundation of the management of neuragenie bladder can be attributed to a pioneer in spinal cord injury medicine. Dr. Donald Munro, a neurosurgeon, who also had experience in urologic surgery, established the firstSpinal Cord lnjury Service of 1 0 beds in the Boston Cityhospital in the 1 930s. He later became adviser to the US Army and the Veterans Administration (VA). On his recommendation, paraplegic centers were created in US army hospitals and later in the VA hospitals from 1 943 to 1945. This article reviews the evolution of the management of neuragenie bladder in patients with spinal cord injuries from the past century to the present. The role of urodynamics in defining neurologic lesions is critical to the appropriate management of the voiding dysfunction. Key advances, such as the diagnosis of detrusor sphincter dyssynergia (DSD), recognition of its association with autonomic dysreflexia, and its definitive management, have been emphasized. The role of transrectallinear array sonography using a rectal probe was found useful for defining bladder outlet dysfunction du ring urodynamics. lt also helped to recognize secondary bladder neck obstruction and diagnose false passages in the urethra. Clean technique intermittent catheterization (IC) was evaluated and recommended. ln about 28'7'o patients with DSD that led to secondary bladder neck obstruction, a consequence of IC was reported. Transurethrallaser sphincterotomy (TURS) was first reported by mein 1 991, and later, durable 7 -yearfollow-up results were reported in 78'7'o of the first 99 patients. We reported a surgical technique to lengthen the penis. We also reported the long-term success with semirigid implants in 92'7'o of patients with SCI. This technique helped maintain external condom drainage on a small phallus and improved the sex life of patients, as weil as their quality of life. The author's pertinent areas of interest in the past one-half century were aimed at recognizing specific urologic problems associated with neurologic impairment. Management was aimed at preventive care, early recognition, and timely management to reduce secondary complications and enhance quality of life.     

Urodynamics: Examining the Current Role of UDS Testing. What is the Role of Urodynamic Testing in Light of Recent AUA Urodynamics and Overactive Bladder Guidelines and the VALUE Study?

Urodynamics testing is a diagnostic assessment of the lower urinary tract system composed of multiple tests to obtain physiologic data regarding lower urinary tract function (detrusor and outlet) during storage and emptying. The necessity of urodynamics has been both supported and challenged in various urologic conditions such as urinary incontinence, neurogenic bladder, lower urinary tract symptoms, and bladder outlet obstruction. This review discusses the most recent studies with regards to the utility of urodynamics in current practice, highlighting the recent American Urologic Association Adult Urodynamics and Overactive Bladder Guidelines and the Value of Urodynamic Evaluation study.     

Laparoscopy-assisted ileal conduit in sacral agenesis

Sacral agenesis is a rare congenital anomaly. The neurologic deficits are usually static. However, there are reports of progressive neurologic deterioration. They have neurogenic bladder, which usually present late and managed according to the presenting urodynamic pattern. In this paper, we report the urologic management in a 4-and-half-year-old boy with sacral agenesis. He presented with constant dribbling owing to gross instability with a small-capacity bladder. He also had bilateral ureteric obstruction (i.e., stricture at the level of bilateral ureteric reimplantation, which was done at the age of 1 year for high-grade reflux). He was not compliant with intermittent self-catheterization. Various options were discussed with the parents, but they preferred an ileal conduit (which could take care of the leak and avoid complex reconstructive surgery), with an option of reconstruction later. Laparoscopic ileal conduit was performed, with the uretero ileal anastomosis and restoration of ileal continuity performed extracorporeally. Extracorporeal part of the procedure was done without any additional incision (by bringing the ureters and ileal segment outside through the 12-mm port and then pushing it back inside after the completion of the anastomosis). We present this case report for the less-morbid management of a complicated urologic problem.     

Urologic Aspects of Traumatic Central Cord Syndrome

ABSTRACT

Central cord syndrome (CCS) is a subset of spinal cord injury, characterized by more motor involvement of the upper extremities than the lower extremities and sacral sensory sparing. Patients with central cord syndrome have been reported to have a good rehabilitation and urologic outcome. Our purpose was to assess the urologic outcome in a group of patients with central cord syndrome.

We reviewed 23 patients with central cord syndrome who were admitted to Hines VA Hospital between 1983 and 1991, 20 of whom were older than 50 years of age. Urodynamic studies showed detrusor hyperreflexia with a synergistic EMG in 15 patients and detrusor hyperreflexia with external urethral sphincter dyssynergia (DSD) in five patients. Three patients with no urologic problems were not tested. Bladder sensation was preserved during filling in all patients. At follow-up (median = 2–4 months), 16 patients (70 percent) were voiding, seven of whom required either occasional external or intermittent catheterization; nine were voiding independently. The seven other patients (30 percent) required either continuous external or intermittent catheterization (including the five with DSD). Urologic morbidity in the period after SCI included: urinary tract infections (12), renal (2) and bladder calculi (2), superficial bladder cancer (1), epididymitis (1) and none (6). Fifteen patients (65 percent) were ambulatory at follow-up while four patients needed wheelchairs. Data were not available for the other four patients. Urodynamic studies in three of the wheelchair-bound patients showed that two of them had DSD.

Most patients with central cord syndrome have favorable urologic and rehabilitation outcomes and can be managed conservatively. A minority of such patients have DSD and they tend to have a less favorable rehabilitation and urologic outcome. A possible neuroanatomic basis for this observation is that these patients have more extensive central cord damage.     

Neurogenic bladder and the lumbar spine

From a large number of patients with urologic symptoms, 8 were selected in six years as having “true neurogenic bladder” with chronic and mild symptoms in the lumbar spine. Symptoms and neurologic and radiologic findings in the preoperative period are described. The type of urologic evaluation is briefly presented with characteristic examples. The postoperative results of these and other series are presented and questioned because of the lack of improvement on urodynamic studies in patients deemed better clinically. The need for a complete evaluation with more sophisticated urologic tests before and after surgery is stressed before a final decision regarding the relation between neurogenic bladder and “asymptomatic” cauda equina compression can be reached.     

脊髓栓系伴神经源性膀胱16例诊治

目的：探讨脊髓栓系伴神经源性膀胱的诊治方法。方法：对26例脊髓栓系伴神经源性膀胱患者的临床资料进行回顾性分析,治疗前所有患者均行尿动力学及腰骶MRI检查,均行解栓术,术后排尿症状均有不同程度改善,再依尿动力学结果采取针对性的治疗方法,A型肉毒素膀胱逼尿肌注射术5例,间歇性清洁导尿2例,膀胱扩大术2例。所有患者治疗后均行尿动力学随访。结果：26例获3个月至3年的随访,其中24例膀胱、尿道功能明显改善,2例需一直行间歇性清洁导尿,但无上尿路恶化。结论：对脊髓栓系伴神经源性膀胱的治疗,无论早晚解栓术都是十分必要的,再根据术后排尿症状采取相应的个性化治疗。     

Initial urologic management of myelomeningocele

Disordered innervation of the detrusor musculature and external sphincter in patients with myelomeningocele adversely affects bladder function and potentially threatens the upper urinary tracts. Children with this condition can be categorized into high and low- risk groups for secondary damage from a neurogenic bladder based on intravesical pressure. Those with elevated pressure are at risk for hydronephrosis or reflux,and evidence suggests that early management of high pressure protects the bladder from additional damage, reducing the need for augmentation. Management decisions made during infancy potentially impact long-term outcomes for preserving renal function and achieving urinary continence. This discussion focuses on the initial urologic care of infants with myelomeningocele, emphasizing the controversy regarding urodynamic versus radiologic-based management of the neurogenic bladder.     

Video urodynamics

Video urodynamics is a technique utilizing synchronously recorded urodynamic studies and cystourethrography for the evaluation of complex lower urinary tract problems. The technique and equipment used in approximately 900 consecutive studies is reported. The value of this method in the investigation of urinary incontinence, complex bladder outlet obstructive states, and neurogenic bladder in particular is presented.     

不稳定膀胱的诊断和治疗

目的探讨不稳定膀胱的诊断及临床治疗效果。方法：通过尿流动力学检查诊断不稳定膀胱，对不同原因者采用不同的治疗方法，包括药物、手术等。结果：尿流动力学检查诊断不稳定膀胱者52例。药物治疗17例，1～2月症状消失者52．9％；手术治疗34例，术后症状好转者94．1％，术后随访28例，尿流动力学检查膀胱稳定者89．3％，其中80％患者梗阻时间短于1年。结论：尿流动力学可明确不稳定膀胱的诊断并指导治疗，有利于患者的康复。     

Surgical management of neurogenic bladder

The neurogenic bladder provides many challenging problems in its treatment. Causation, proper urologic evaluation, and treatment of neurogenic bladder are discussed with emphasis on surgical techniques, such as relieving distal obstruction, alternative measures of urinary diversion, and the use of vesical stimulators. Preservation of renal function is the prime objective of all modes of therapy.     

Clinical study of bunazosin hydrochloride, an alpha 1-adrenergic blocker, in benign prostatic obstruction and neurogenic bladder dysfunction

A newly developed alpha 1-adrenergic blocker, bunazosin hydrochloride (Detantol, Eisai) was clinically investigated in 17 patients with benign prostatic obstruction and 18 patients with neurogenic bladder dysfunction. Subjective symptoms improved in 11 of the 17 cases (64.7%) with prostatic obstruction and in 4 of the 10 cases (40%) with neurogenic bladder dysfunction. Dose-dependent subjective improvement was observed with dosages of 3 to 9 mg/day. A dosage of 12 mg/day did not improve subjective symptoms more than did the 9 mg/day dose. In prostatic obstruction, 7 of the 10 objective parameters improved significantly. However, for neurogenic bladder dysfunction, only two parameters improved significantly. Improvements in objective findings were generally dose-dependent in cases of prostatic obstruction, but not in neurogenic bladder dysfunction. Mild side effects, none of them serious, were reported in 9 of the total 35 cases (26%). They generally consisted of dizziness, nasal obstruction and headache. Comprehensive improvement, i.e., improvement of both subjective symptoms and objective parameters, occurred in 11 of the 17 cases (64.7%) of prostatic obstruction and 6 of the 18 cases (33.3%) of neurogenic bladder dysfunction.     

Overactive bladder and men: Indications for anticholinergics

Similar to bladder outlet obstruction (BOO), overactive bladder (OAB) symptoms are very common and increase in prevalence as men age. Whether or not OAB symptoms are thought to be secondary to BOO, the goal of treatment of symptoms should result in an improved quality of life and ultimately prevent clinical deterioration. A common dilemma when treating men with obstruction and OAB is the risk of acute urinary retention or morbidities related to increasing postvoid residuals. In this article, the relationship of OAB to BOO is examined and the role of urodynamics and data on the use of anticholinergics in men with OAB and obstruction are reviewed. An algorithm for managing men with OAB also is proposed. In men with OAB without evidence of obstruction (including OAB after treatment for BOO), first-line medical therapy with anticholinergics is indicated. However, in men with OAB and concomitant BOO, nomogram has been developed to assist in the management of patients at risk for urinary retention. Men with significant obstruction should be appropriately treated to decrease bladder outlet resistance before adding anticholinergics for the treatment of OAB.     

Neurogenic bladder dysfunction in sacral agenesis and dysgenesis

In seven adult patients suffering from congenital caudal spinal malformations including total agenesis, dysgenesis, and dysraphism of the sacral bones, the neurological and the neurogenic bladder disorders are described. Based upon clinical, radiological, and urodynamic investigations, previous observations were confirmed of the wide spectrum of micturition disorders in this type of patient. In three females and four males (median age 30 years, range 19–51 years) a wide spectrum of neurogenic bladder disorders ranging from complete suprasacral to complete infrasacral lesions was found. In one patient, no evidence of sensory-motor bladder nerve deficiency was found. The finding of neurologic damage not corresponding to the levels of bone lesions and the high proportion of patients suffering from concurrent genitourinary developmental defects should emphasize the need for thorough and frequent investigations including urodynamics and monitoring of renal function.     

The role of urodynamics in the treatment of lower urinary tract symptoms in women

PURPOSE OF REVIEW: Urodynamic investigation was developed as an extension of patient history and physical examination in order to reveal the pathology of a patient's complaints. Much progress in standardizing definitions and procedures has been made in recent years. In particular, stress urinary incontinence and overactive bladder can be differentiated with urodynamics. The developed parameters, however, cannot distinguish the various types of stress urinary incontinence. Moreover the definition and diagnosis of voiding dysfunction is not clear. Finally our understanding of bladder sensations and the impact on voiding behaviour has only started to emerge. This review is about last year's publications that focus on urodynamics and lower urinary tract symptoms in women. RECENT FINDINGS: Defining bladder outlet obstruction is based on voiding pressure, urinary flow speed and residual urine but standardization is lacking. Urodynamics to reveal occult stress urinary incontinence in patients with pelvic organ prolapse needs standardization of the reducing manoeuvres. The quest for urodynamic tools for distinguishing intrinsic sphincter deficiency from urethral hypermobility continues. Urodynamics are still not good enough to discriminate between treatment options for stress urinary incontinence. The use of urodynamics in overactive bladder is developing and has elicited new findings. Voiding habit seems to be independent from bladder sensations. Also bladder sensations appear to be imperfectly correlated with bladder filling. Even bladder volumes do not predict entirely bladder fullness sensations. SUMMARY: In order to use urodynamics as a proper clinical tool, defining subtypes of stress urinary incontinence and standardization of urodynamics in pelvic organ prolapse and bladder outlet obstruction in women is needed.     

Urologic complications of the neurogenic bladder

Patients with a neurogenic bladder are at risk for several urologic complications including hydronephrosis, vesicoureteral reflux, renal failure, urinary tract infections, calculus disease, bladder cancer, sexual dysfunction including infertility, and the destroyed bladder and urethra. The management of filling bladder pressures and regular, complete emptying, ideally with clean intermittent catheterization, can prevent or delay many of these complications. Even with optimum management, complications may still develop over time, necessitating regular urologic follow-up to recognize, treat, and prevent further complications. The ultimate goal of the urologist in treating the patient with a neurogenic bladder is to allow for preservation of renal function and continence with minimum complications.     

Progress in urodynamic research on the upper urinary tract: implications for practical urology

The development of new surgical techniques for bladder substitution and continent urinary diversion has extended interest in urodynamics of the upper urinary tract. From a subdiscipline attracting mainly scientists and bioengineers, renal pelvic kinetics and ureteral peristalsis have evolved as important factors in routine clinical urology. The observed changes in peristaltic pattern during high diuresis, obstruction and urinary reflux have influenced management of stone disease and neurogenic bladder. The demonstration that high intravesical pressure is reflected to the kidney not only when the ureteric orifice is incompetent, but also during high diuresis, established the necessity for low pressures in neobladders. Much further clarification of urinary transport from the renal tubules to the bladder should be achievable by refined techniques of fluoroscopy, isotopic renography and manometry.     

How does the presence of urologic problems change the outcome of kidney transplantation in the pediatric age group

PURPOSE: We retrospectively reviewed the impact of functional and anatomic urologic disorders on kidney transplantation outcomes in terms of the surgical and long-term results of pediatric renal transplantation. MATERIALS AND METHODS: Of the 55 kidney transplantations in the pediatric age group, end-stage renal disease (ESRD) was secondary to genitourinary disorders in 23 patients (42%). The urologic abnormalities were vesicoureteral reflux in 13 patients (59%), neurogenic bladder in 4 patients (18%), posterior urethral valves in 3 patients (14%), renal stone disease in 4 patients (18%), bilateral ureterovesical junction obstruction in 3 patients (14%), and unilateral renal agenesis with concomitant contralateral ureteropelvic junction obstruction in 1 patient (4%). RESULTS: Of the 23 patients with urologic problems, 19 (83%) had functioning grafts with a mean follow-up of 49 months (range, 7-120 months). In the other 32 patients, 26 (81%) had functioning grafts with a mean follow-up of 43 months (range, 1-144 months). The graft survival, mean serum creatinine, and urinary tract infection rates of the patients did not differ between the two groups. CONCLUSIONS: The presence of functional urologic disorders as the cause of ESRD did not seem to change the outcome of renal transplantation in terms of graft survival when compared with patients without any urologic disorders. Urinary tract infections seem to be a little more common and yet clinically not significant in those patients. Reflux does not always need to be corrected before transplantation, unless it is causing symptoms or infection.     

Voiding dysfunction in patients with spastic paraplegia: Urodynamic evaluation and response to continuous intrathecal baclofen

Patients with hereditary spastic paraplegia (HSP), a degenerative central nervous system disorder characterized by progressive lower extremity spasticity, frequently experience symptoms of voiding dysfunction. Urodynamic evaluation of patients with HSP has not been reported, and the etiology of voiding dysfunction remains unexplained. We present our evaluation of three men (ages 42–62 years) with this rare syndrome. Urgency of urination was a uniform and dominant complaint, and two patients regularly experienced urge incontinence. Other symptoms included frequency (n = 3), nocturia (n = 3), and diminished force of stream (n = 1). Postvoid residual volumes were less than 25 ml in all patients. On urodynamic evaluation the two patients with urge incontinence displayed cystometric evidence of involuntary detrusor contractions. Pelvic floor EMG recordings suggested detrusor-sphincter dyssynergia (DSD). In addition, one patient exhibited markedly diminished bladder compliance (1.0 ml/cm H₂O) and capacity (50 ml). AH patients reported marked symptomatic improvement when treated with continuous intrathecal baclofen. Evaluation during baclofen treatment revealed increases in bladder compliance and capacity, with apparent resolution of DSD in one patient. Voiding symptoms in these patients most likely arise from a neurogenic etiology; however, a contributory role for chronic outlet obstruction from striated muscle spasticity may also exist.     

Gynecological urologic disease: a summary of clinical experience during the last 4 years at Wakayama Red Cross Hospital

From April 1979 to March 1983, sixty seven patients with gynecological urologic disease were experienced at our department. Forty one of them were inpatients, i.e., 15.3% of the total number of female in patients admitted during the same period. Thirty three urologic operations were performed on them which corresponded to 16.1% of the total operations on female patients. Ten of these patients had ureteral obstruction following gynecological operation, 8 had ureteral fistula, 7 had vesicovaginal fistula, 11 had tumor invasion to urinary tract, 14 had radiation cystitis, 16 had neurogenic bladder dysfunction, and 1 had other complication. The treatment of these patients and the results are summarized and discussed.