The Spastic Sphincter

1
The Spastic Sphincter

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

2
Function of urethral sphincter

• Provide adequate urethral resistance at filling
  phase to prevent incontinence
• Active relaxation during voiding phase for
  micturition
• Inhibition of detrusor nucleus to postpone
  voiding before threshold
• Release of inhibitory effect on detrusor nucleus
  at initiation of voiding (on-off switch)

3
Anatomy of male urethral sphincter
4
Anatomy of FemaleUrethral sphincter
5
Toilet training A learning process influences
voiding

• Traditional voiding control by age 3
• CNS plasticity and adaptation to sensory input of
  micturition process
• Retentive behavior of children
• Parent pushing of toilet training
• Behavioral stress to muscles and change in
  functional integrity of tissue

6
The overactive sphincter

• Incorrect conditioning of voiding reflexes during
  CNS maturing
• Symptoms ranging from incontinence to retention
• Chronic LUT dysfunction is maintained by
  permanently up-regulated sacral reflex arcs
• Dysfunctional voiding develops

7
The Pelvic Floor

• Deep layer Levator ani provide relaxation
  during micturition and defecation (S3,4),
  contraction to lift pelvic organ upward and
  compression
• Transverse perinealis, ischeocavernous,
  bulbocavernous, urethral sphincter, anal
  sphincter muscles (S2) provide squeezing effect
  on pelvic organs

8
Anatomy of Pelvic Floor
9
Innervation of Pelvic Floor

• Perineal skin sensation from S2 nerve
• Skin sensation can be impaired unilaterally or
  bilaterally in S2 nerves
• Loss of skin sensation often reflects a loss of
  urethral sphincter integrity
• Deficits in S3,4 nerves are not associated with
  significant incontinence
• Hypersensitivity of bladder is often mirrored
  hypersensitivity of the levator (S3,4)

10
Neuroregulation of sacral nerves in micturition
reflex

• Loss of pudendal afferent input can dampen the
  detrusor reflex
• Enhanced afferent input to micturition center can
  augment detrusor reflex
• Supraspinal inhibition or increased inhibitory
  input to micturition center can suppress detrusor
  reflex
• Chronic anxiety or via behavioral pathway can
  cause loss of volitional or ability to relax the
  sphincter with void efforts

11
Pathophysiology of pelvic floor dysfunction

• Changes in peptide release from nerve endings
  secondary to stress (supraspinal)
• Enhanced release of inflammatory or
  neural-sensitizing peptides into tissue (local
  inflammation)
• Inadequate pelvic floor control due to learned
  behavior (dysfunctional voiding)

12
Detrusor instability and Holding urine during
involuntary DI
13
CNS Control of Pelvic floor

• Medial part of dorsal pontine tegmentum
  (M-region) sphincter relaxation and detrusor
  contraction
• Lateral part of pontine tegmentum sphincter
  contraction and detrusor inhibition
• Onufs nucleus spinal control center of pelvic
  floor linkage to paraventricular nucleus

14
Micturition and Continence center in CNS
15
Central peptide pools linked to CNS centers
regulating LUT function
Paraventricular peptide pool Paraventricular peptide pool
Vasopressin, oxytocin, substance P
Somatostatin, dopamine, neurotensin
Glucagon, renin
Corticotropin-releasing factor
Met- and leu-enkephalin
Nucleus Onuf peptides (for sphincter control) Nucleus Onuf peptides (for sphincter control)
Somatostatin, neuropeptide Y, serotonin
Substance P (from paraventricular nucleus, dorsal and ventral roots)
Met-and leu-enkephalin
16
Neurobiological background of pelvic floor
dysfunction
17
Clinical assessment of a hypertonic pelvic floor

• LUT Symptoms frequency, urgency, suprapubic,
  perineal, deep pelvic pain, lower backpain, slow
  stream, intermittency, recurrent UTI, retention
• Constipation or difficult defecation
• Sexual dysfunction
• Insomnia and other somatic complaints

18
Important past history
Current symptoms? Current symptoms? Current symptoms?
Since when? development over the last time? change in last time? Since when? development over the last time? change in last time?
Pain? Pain?
Where?, character?, intensity (using visual analog scale 0-10), Change over time?
Micturition? Micturition?
Any problems?, double voiding?, infections?m burning?, inability to void?
Defecation? Defecation?
Frequency, consistency
Sexual life? Sexual life?
Dysfunction?, emotional problems?, female vaginism?
Childhood Childhood
prolonged bedwetting?, excessive exercises to achieve early urinary continence?, punishment for bedwetting?, retentive voiding habits (I.e.,low micturition frequency?), sexual abuse (female)?
Adolescence Adolescence
Femalepainful menses?,frequent urinary tract infections?
Maleurinary tract infections
Adulthood Adulthood
Female childbirths?, vaginal delivery?, pelvic surgery?, infections?, voiding habits over time,profession, personal satisfaction
Malevoiding habits, profession,social life
19
Hypertonic pelvic floor hypertonic urethral
sphincter?

• Urethral sphincter and external anal sphincter
  are mainly innervated by S2
• Levator ani are innervated by S3,4
• Reflex coordination to bladder sensory input is
  synchronized in most of cases
• Isolated denervation or impairment in conduction
  may occur

20
Hypertonic urethral sphincter Straining to
initiate voiding
21
Hypertonic urethral sphincterStraining to open
urethra
22
Hypertonic urethra hyperactive urethra?

• Hypertonic urethra indicates increased and
  sustained urethral pressure (tonic) during
  resting state
• Hyperactive urethra indicates increased activity
  of urethral sphincter during voiding state
• A spastic urethral sphincter causes difficulty in
  initiation of voiding

23
Hyperactive urethral sphincterduring initiation
voiding
24
SCI with type 1 DESD and low detrusor
contractility
25
States of dysfunctional voiding due to spastic
sphincter
1. Fill phase (normally very stable pressure 60-80 cmH2O) 1. Fill phase (normally very stable pressure 60-80 cmH2O) 1. Fill phase (normally very stable pressure 60-80 cmH2O)
Pathology High sphincter pressure (gt80)
Hypersensitivity
Clonic or hyperreflexic dynamic
Spasms (pain)versus spontaneous relaxations (leakage episodes)
2.Transition phase (normally smooth) 2.Transition phase (normally smooth) 2.Transition phase (normally smooth)
Pathology Nonrelaxation
Hesitant/delayed relaxation
Precipitous relaxation
Aborted relaxation
Rising sphincter pressures
3.Void phase (normally coordinated) 3.Void phase (normally coordinated) 3.Void phase (normally coordinated)
Pathology Partial relaxations
Intermittency of sphincter relaxation
4.Recovery stage (normally smooth) 4.Recovery stage (normally smooth) 4.Recovery stage (normally smooth)
Pathology Intermittency (dribbling)
26
Clinical assessment of pelvic floor muscle
function

• Uterine prolapse or cystocele
• Sensation of perineal skin
• Anal tone measurement
• Volitional contraction of pelvic floor
• Search for inflammatory sources (hemorrhoid,
  prostatitis, vaginitis)
• Focal neurological findings (Bulbocavernous
  reflex, deep tendon reflex)

27
Digital rectal examination of Pelvic floor muscles

• Deep and superficial sphincter muscle tone, weak,
  high, or normal?
• Hypersensitivity or tenderness of the levator or
  urethral sphincter
• Motor identity of sphincter muscles or levator
  ani muscles
• Voluntary repetitive contractions of sphincter
  and levator muscles

28
Tentative diagnosis of pelvic floor hypertonicity

• Spastic urethral sphincter a chronic hypertonic
  urethral sphincter causing functional bladder
  outlet obstruction
• Poor relaxation of pelvic floor muscles
  inadequate relaxation during voiding causing
  hesitancy, low intermittent flow
• Non-relaxing pelvic floor or urethral sphincter
  -- no relaxation during voiding efforts by
  abdominal straining or Valsalva maneuver

29
Diagnosis based on initial investigations

• LUT symptoms
• Negative urinalysis or urine culture
• High pelvic floor muscle tone
• Low maximal flow rate and obstructive
  intermittent flow pattern
• No evidence of BPH or other pathology
• Voiding diary verified LUTS

30
VUDS Analysis in 112 Non-obstructive Men with LUTS

• Normal bladder urethra 25 (22.3)
• Hypersensitive bladder 17 (15.2)
• Detrusor instability 6 (4.5)
• Detrusor failure 3 (2.7)
• Poor relaxed external sphincter 61(54.5)

31
Urodynamics

• Uroflowmetry EMG
• Cystometrogram EMG
• Pressure flow study
• Videourodynamic study
• Urethral pressure profilometry
• Pudendal nerve latency time
• Evoke potential study

32
Intermittent Flow
33
Relaxation of urethral sphincter at initiation of
voiding
34
Poor relaxation of urethral sphincter during
voiding
35
Intermittency due to poor relaxation of ES
36
Pseudodyssynergia in CVA causing high voiding
pressure
37
Inhibition of detrusor contraction by urethral
sphincter during voiding
38
Stop test volitional sphincter contraction and
inhibition of voiding
39
Guarding reflex during uninhibited detrusor
contractions
40
Coordinated sphincter activity during filling
phase in Enterocystoplasty
41
Increased sphincter activity causing isolated
obstruction in detrusor areflexia
42
DHIC and increased sphincter activity during
filling
43
Detrusor overactivity and overactive sphincter
pelvic floor
44
Type I DESD in C5,6 SCI
45
Type II DESD in Thoracic SCI
46
Urethral sphincter v Pelvic floor muscles
analogue?
47
Discoordinated urethral sphincter in
dysfunctional voiding
48
Chronic pelvic floor spasticity A cause of
pelvic pain?

• Increased muscle tone of pelvic floor muscles
• Spasticity of urethral sphincter
• Spasticity of external anal sphincter
• Hypertonicity of pyriformis muscles
• Fascitis of pubococcygeus or coccygeus muscles
• Physiotherapy and medication for pelvic floor
  spasticity can relieve pelvic pain
• Should search for tendered points or infection

49
Chronic prostatitis syndrome

• Symptoms of frequency, urethral irritation,
  hesitancy, intermittency, residual urine
  sensation, perineal pain and lower back pain
• Spastic urethral sphincter might be a cause of
  chronic prostatitis or reflux abacterial
  prostatitis
• Treated as spastic sphincter may work

50
Spastic urethral syndrome and constipation

• Chronic constipation causes hypertonic anal
  sphincter and hence, pelvic floor muscles
• Poor relaxation of pelvic floor muscles results
  in inhibition of detrusor contractions during
  voiding
• Concomitant treatment of constipation can relieve
  voiding symptoms

51
Treatment of spastic urethral sphincter

• Behavioral therapy hydration, laxatives, time
  voiding, changing voiding posture
• Physiotherapy pelvic floor muscle exercises
• Electric stimulation interferential current
  stimulation
• Biofeedback visual or Uroflowmetry EMG
• Medication baclofen, alpha-adrenergic blockers,
  estrogen, combination therapy
• Urethral injection of botulinum A toxin

52
Therapeutic results of baclofen and terazosin in
treatment of spastic urethral sphincter
IPSS IPSS IPSS Qmax Qmax Qmax Residual urine Residual urine Residual urine
Baseline Trated Baseline Treated Baseline Treated
Baclofen (n73) 15.26.7 10.45.7 14.39.7 16.78.1 65.733.9 37.521.7
of change 31.621.5 31.621.5 31.621.5 16.8712.7 16.8712.7 16.8712.7 42.934.1 42.934.1 42.934.1
Baclofen plus 12.77.9 61.4.5 14.811.0 22.677.5 58.121.8 31.0131.2
Terazosin (n64) Terazosin (n64)
of change 51.727.4 51.727.4 51.727.4 52.731.1 52.731.1 52.731.1 46.529.3 46.529.3 46.529.3
Statistics Plt0.05 Plt0.05 Plt0.05 Plt0.05 Plt0.05 Plt0.05 NS NS NS
53
Biofeedback pelvic floor muscle relaxation
54
Strengthened PFM after 3 M training
55
Botulinum A toxin
56
Identification of External Sphincter in Man
57
Preliminary Result inReduction of MUCP
58
(No Transcript)
59
Results of Botulinum A Toxin in Patients with
Voiding Dysfunction
Good Improved Failed
Detrusor underactivity (n27) 13 (48.2) 8 (29.6) 6 (22.2)
DESD (n18) 3 (16.7) 10 (55.6) 5 (27.8)
Dysfunctional voiding (n18) 6 (33.3) 10 (55.6) 2 (11)
Poor relaxation of urethral sphincter (n12) 3 (25) 7 (58.3) 2 (16.6)
TOTAL (n75) 25 (33.3) 35 (43.7) 15 (20)
DESDDetrsor external sphincter dyssynergia
60
Influence of Detrusor contractility and Urethral
sphincter activity on Botox Effects
Good Improved Failed
High pressure contractility (n26) 8 (30.7) 15 (57.6) 3 (11.5)
Low pressure contractility (n49) 17 (34.6) 20 (40.8) 12 (24.4)
No-relaxing sphincter (n27) 13 (48.2) 8 (29.6) 6 (22.2)
Hyperactive or poorly relaxed urethral sphincter (n48) 12 (25) 27 (56.2) 9 (18.7)
TOTAL (n75) 25 (33.3) 35 (43.7) 15 (20)