Peripheral Neuropathy and Neurogenic Voiding Dysfunction

1
Peripheral Neuropathy and Neurogenic Voiding
Dysfunction

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

2
Peripheral neuropathy

• Cauda equina syndrome
• Sacral root injury
• Pelvic plexus injury
• Diabetes neuropathy
• Detrusor denervation

3
Consequences of peripheral neuropathy

• Detrusor contractions are lost
• Bladder becomes an acontractile sac
• Bladder empty by abdominal straining or
  suprapubic compression (Crede maneuver) or
  catheterization
• Bladder sensation becomes vague

4
Lower urinary tract symptoms in Peripheral
neuropathy

• Dysuria
• Straining to void
• Frequency
• Residual urine sensation
• Urinary incontinence (overflow)
• Urinary retention

5
Physiology of micturition
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6
Cauda equina lesion

• Lumbar spinal injury
• Surgery for herniated disc
• Complete or incomplete injury to nerve roots
• Detrusor contractility is lost in complete lesion
• Recovery of detrusor contractility depends on
  severity of lesion

7
Diagnosis of Cauda equina lesion

• History of surgical trauma
• Dysuria and straining to void after spine surgery
• Constipation is the rule
• Saddle anesthesia or paresthesia
• Lower extremity motor deficiency

8
Urodynamics of Cauda equina lesion

• Detrusor areflexia at initial stage, sphincter
  tone is fixed (normal or weak)
• Bladder sensation of filling is normal or vague
• Bladder neck may be closed or open
• Bladder compliance is normal initially
• Patients void by abdominal straining

9
Detrusor areflexia after cauda equina lesion
10
Isolated sphincter obstruction in cauda equina
lesions
11
Bladder outlet in Cauda equina lesion

• Bladder neck may be closed due to lack of
  synchronized relaxation during volitional voiding
• Benign prostatic enlargement may increase
  urethral resistance
• Isolated striated urethral sphincter results in
  bladder outlet obstruction

12
Bladder outlet obstruction due to BPH in cauda
equina lesion
13
Persistent dysuria after TURP in cauda equina
lesion
14
Chronic LUTD afterCauda equina lesion

• Bladder compliance turns lower than normal
• Bladder sensation remains vague
• In isolated urethral sphincter obstruction the
  bladder neck is open and trabeculated bladder
  develops
• In low urethral resistance, the bladder maintains
  a low pressure reservoir

15
Trabeculated and poor compliant bladder in cauda
equina lesions

16
Obstructive uropathy in chronic cauda equina
lesions
17
Meningomyelocele with detrusor areflexia closed
bladder neck
18
Cauda equina lesion with high urethral resistance
dysuria
19
Cauda equina lesion with low urethral resistance,
normal flow
20
Management of NVD after Cauda equina lesion

• Clean intermittent self catheterization should be
  instructed especially in women
• Suprapubic cystostomy may be instituted in men
• Urecholine can increase intravesical pressure and
  facilitate straining to void
• Alpha-blocker and striated skeletal muscle
  relaxant (Baclofen or diazepam)my be helpful

21
Surgical consideration for NVD after cauda equina
lesions

• Transurethral resection of prostate may be
  performed in patients with an enlarged prostate
  and increased urethral resistance
• Transurethral bladder neck incision for those
  with a tight bladder neck
• Incontinence may be a complication after
  transurethral surgery

22
Sacral roots injury and NVD

• After spine surgery or trauma
• Urodynamic changes as cauda equina lesions
• Transient detrusor underactivity with normal or
  absent bladder sensation
• Lower urinary tract dysfunction depends on
  complexity of nerve injuries

23
Pelvic plexus injury

• Almost always trauma and iatrogenic
• Radical surgery for cervcal cancer and rectal
  cancer
• Pelvic fracture with severe intrapelvic hematoma

24
Neuroanatomy of pelvic plexus
25
Pelvic plexus

• Formed by the confluence of pelvic
  parasympathetic nerves with sympathetic
  hypogastric nerves
• Pelvic plexus contains ganglia where
  parasympathetic nerves and sympathetic nerves
  interact synchronously
• One side pelvic plexus injury does not influence
  voiding function

26
The Pelvic Ganglia
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27
Location of pelvic plexus

• In men, posterior plexus lies close to the
  anterolateral wall of lower rectum and anterior
  plexus at posterolateral aspect of prostate and
  seminal vesicles
• In women, anteromedial plexus at upper part of
  vagina, below broad ligament and extend to
  cardinal ligament

28
Neuroanatomy of pelvic plexus
29
Radical abdominal hystertectomy

• Damage of plexus when excision extend to level of
  cardinal ligament or a long cuff vaginal excision
• Ureter lies above plexus, avoid ureteral injury
  will prevent plexus injury
• Limited lymph node dissection in the side without
  cervical cancer reduces postoperative voiding
  problem

30
Rectal cancer surgery

• Pelvic plexuses are vulnerable to injury during
  radical rectal surgery
• Pelvic plexuses share the same fascial sheath
  with the lower rectum
• Pudendal nerve may be damaged concomitantly
  during abdominoperineal resection of rectum (APR)

31
Neuroanatomy of Pudendal nerves
32
Consequences of pelvic plexus injury

• Parasympathetic decentralization and leave the
  ganglia in the plexus or detrusor muscles
• Sympathetic denervation and loss of coordinated
  regulation with parasympathetic nerves
• Sensory afferent nerves injury and loss of
  awareness of bladder filling

33
Urodynamic changes after pelvic plexus injury

• Detrusor areflexia immediately after injury
• Bladder sensation becomes vague and through
  peritoneal layer sensation
• The bladder neck is loose and can be opened by
  increased intravesical pressure
• Urethral sphincter tone may not change

34
Urodynamic changes after radical hysterectomy

• Recovery of detrusor contractility is usually
  incomplete takes 6-12 months
• Significant residual urine in the women with
  lower abdominal straining pressure
• Bladder neck incompetence and isolated sphincter
  obstruction
• Urethral sphincter EMG activity may synchronously
  increased at bladder filling

35
Changes in bladder compliance after radical
hysterectomy
A (n47) B (n47) C (n47) D (n47) P value lt0.05 gt0.05
Residuum (ml) 6.611.03 289.5724.95 140.8319.90 65.7411.42 A - B A - C A - D B - C B - D C - D
Rest. P. (cm H2O) 12.170.70 10.910.67 10.830.65 18.530.76 A - D A - B B - D A - C C - D B - C
FSF (ml) 126.056.56 249.5715.15b 215.3315.36c 300.5115.56d A - B B - C A - C A - D B - D C - D
Capacity (ml) 268.5111.48 334.0412.81 353.3311.67 380.4217.65 A - B B - C A - C C - D A - D B - D
Compliance (ml/cm H2O) 53.516.28 7.290.96 13.331.61 19.172.56 A - B C - D A - C A - D B - C B - D
36
Large compliant and hypotonic bladder after
radical hysterectomy
37
Detrusor areflexia and large bladder compliance
after radical hysterectomy
38
Fair compliant and normotonic bladder after
radical hysterectomy
39
Persistent poor compliant bladder after radical
hysterectomy
40
Poor bladder compliance after Radical hysterectomy
41
Changes in urethral closure pressure after
radical hysterectomy
MUCP (cm H2O) FPL (cm)
A 84.143.75 2.960.10
B 60.213.20 2.650.10
C 52.01.77 2.790.09
D 78.083.86 3.090.01
P value A-B,A-C,B-D,C-Dlt0.05 A-D,B-C gt0.05 A-B,A-C,B-D,C-Dlt0.05 A-D,B-C gt0.05
42
Lower urinary tract dysfunction after radical
hysterectomy

• Dysuria and straining to void
• Urinary stress incontinence due to low bladder
  compliance or reduced bladder outlet resistance (
  bladder neck incompetence or urethral sphincter
  insufficiency)
• Upper tract deterioration in chronic cases

43
Isolated sphincter obstruction after radical
hysterectomy
44
Poor bladder compliance with low urethral
resistance
45
Incontinence in Poor bladder compliance with
relaxed urethral sphincter
46
Normal bladder compliance with low urethral
resistance and SUI
47
Complications of pelvic plexus injury

• Large residual urine
• Frequent urinary tract infection
• Overflow incontinence
• Hydronephrosis
• Azotemia and renal scarring
• End stage renal failure

48
Upper tract deterioration after Radical
hysterectomy

• Chronic urinary retention and poor bladder
  compliance
• Patients suffer from incontinence, frequent
  cystitis, frequent pyelonephritis
• Occur when radiotherapy was performed in addition
  to radical hysterectomy
• A tight urethral sphincter is present

49
Contracted bladder with Bilateral VU reflux
50
Management of LUTD after pelvic plexus injury
Difficult urination

• Behavior therapy timed voiding
• Medication urecholine, alpha-blocker, striated
  muscle relaxant, nitric oxide donors
• Clean intermittent catheterization
• Periurethral injection of botulinum toxin

51
Botulinum toxin A urethral injection

• Dysuria after radical hysterectomy results from
  detrusor underactivity and a hypertonic urethral
  striated sphincter
• Botulinum toxin A exerts a paralytic effect on
  striated muscle
• 50 to 100 units botulinum toxin is effective in
  reducing sphincteric tone and facilitate voiding
  by abdominal straining

52
Reduced voiding pressure after botulinum A toxin
injection
53
Reduction in MUCP after Botulinum A toxin
injection
54
Management of LUTD after pelvic plexus injury --
Incontinence

• Behavioral therapy timed voiding according to
  urodynamic results
• Medication methylephedrine, imipramine
• Surgery periurethral collagen or Teflon
  injection
• Surgery pubovaginal sling procedure
• Urinary diversion Kock pouch, ileal conduit,
  ureterostomy, nephrostomy

55
Management of LUTD after pelvic plexus injury
mixed dysuria and incontinence

• Urodynamic evaluation of upper tract dysfunction
• Incontinence should not be treated in a poor
  compliant bladder
• Clean intermittent catheterization after
  anti-incontinence surgery is feasible
• Weigh the need of patient and side effects after
  management

56
Management of LUTD after pelvic plexus injury --
hydronephrosis

• Bilateral hydronephrosis develop in chronic poor
  bladder compliance
• Clean intermittent catheterization in patients
  with fair bladder capacity
• Augmentation cystoplasty to treat patients with
  both hydronephrosis and incontinence
• CISC may be necessary after bladder augmentation
• Avoid surgery if Cr gt2.5 or CCrlt10ml/min

57
Improved in hydronephrosis after augmentation
cystoplasty
58
Lower urinary tract dysfunction after radical
rectal surgery

• Urinary retention detrusor areflexia or
  underactivity after surgery
• Urinary incontinence urethral sphincter
  insufficiency due to pudendal nerve injury
• Overflow incontinence and poor bladder compliance
  are not common findings

59
Videourodynamic study after Abdominoperineal
resection of Rectum
60
Lower urinary tract dysfunction after radical
rectal surgery

• Dysuria and large residual urine detrusor
  areflexia or underactivity
• Combined with bladder outlet obstruction such as
  BN dysfunction or benign prostatic enlargement
• Cystocele formation after APR lack of posterior
  support

61
Treatment of difficult urination or incontinence
after APR

• Dysuria may be treated with Crede maneuver,
  intermittent catheterization, or alpha-blocker
• Incontinence may be treated with periurethral
  collagen or Teflon injection, sympathomimetic
  agent
• Avoid prostatectomy in patients with detrusor
  areflexia, incontinence might be a postoperative
  complication