Neurogenic Voiding Dysfunction

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Neurogenic Voiding Dysfunction

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

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Complications of Neurogenic voiding dysfunction

• Severe lower urinary tract symptoms dysuria,
  incontinence, retention
• Urinary tract infection APN, cystitis,
  prostatitis, epididymitis
• Renal function impairment hydronephrosis,
  vesicoureteral reflux, renal scarring, ESRD

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Objectives of urological care for neurogenic
voiding dysfunction

• Preservation of renal function
• Adequate bladder emptying
• Prevention of UTI
• Establishment of continence
• Freedom of catheter
• Spontaneous voiding

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Treatment of NVD

• Based on pathophysiology of NVD
• Patients self-handling capability
• Family support
• Convenience of medical care
• Patients will of management

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Neurogenic Voiding Dysfunction (1997-2002)
?. Intracranial Lesion (n141) CVA 113
?. Intracranial Lesion (n141) Parkinsons disease 18
?. Intracranial Lesion (n141) Dementia 3
?. Intracranial Lesion (n141) ICH 7
?. Spinal Cord Lesion (n195) Cervical 78
?. Spinal Cord Lesion (n195) Thoracic 69
?. Spinal Cord Lesion (n195) Lumbar 25
?. Spinal Cord Lesion (n195) Sacral 23
?. Cauda equina lesion 17
?. Peripheral neuropathy (n57) Cervical Ca 43
?. Peripheral neuropathy (n57) Rectal Ca 7
?. Peripheral neuropathy (n57) Others 10
?. DM 109
Total 519
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Symptomatology of Neurogenic Voiding dysfunction
Urine rectention Incontinence Frequency urgency Dysuria UTI
Intracranial Lesion (n141) 43 (30.5) 69 (48.9) 41 (29.1) 79 (56) 58 (41.1)
SCI (n195) 44 (22.6) 80 (41) 16 (8.2) 79 (39) 103 (52.8)
Cauda equina lesion (n17) 4 (23.5) 10 (58.8) 4 (23.5) 9 (52.9) 4 (23.5)
Peripheral neuropathy (n57) 7 (12.3) 31 (54.4) 17 (29.8) 36 (63.2) 19 (33.3)
DM (n109) 36 (33) 45 (41.3) 35 (32.1) 56 (51.4) 63 (57.8)
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Normal Micturition

• Cortical arousal and initiation of voiding
• Normal detrusor contractility
• Normal cortical inhibition before voiding
• Patent bladder outlet and urethra
• Coordinated external sphincter during detrusor
  contraction
• Volitional contraction of sphincter and
  interruption of voiding

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Normal Micturition
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Physiology of Micturition

• Micturition reflex center sacral cords S2-4
• Micturition center pons
• Sensory and motor cortex frontal lobe
• Coordination of detrusor and striated sphincter
  cerebellum,basal ganglia
• Affection influence limbic system

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Diagram of Micurition reflex
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Urodynamic Classification NVD

• Cerebral lesion detrusor areflexia detrusor
  hyperreflexia with coordinated external sphincter
• Suprasacral cord lesion autonomic dysreflexia
  (lesion above T6) detrusor hyperreflexia with
  external sphincter dyssynergia

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Urodynamic Classification NVD

• Sacral cord lesion detrusor areflexia with
  non-relaxing urethra atonic urethra
• Peripheral neuropathy detrusor areflexia with
  discoordinated urethral sphincter

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Urodynamic findings in Neurogenic Voiding
dysfunction
Detrusor areflexia Detrusor hyperaflexia DHIC
?.Intracraniall Lesion (n141) 13 (9.2) 128 (90.8) 51 (36.2)
?.SCI (n195)
Cervical (78) 6 (7.7) 72 (92.3) 13 (16.7)
Thoracic (69) 28 (40.6) 41 (59.4) 10 (14.5)
Lumbar (25) 13 (52) 12 (484) 3 (12.0)
Sacral (23) 13 (56.5) 10 (43.5) 5 (21.7)
?.Cauda equina lesion (n17) 13 (76.5) 4 (23.5) 4 (23.5)
?.Peripheral neuropathy (n57) 49 (86) 8 (14) 8 (14)
?.DM (n109) 20 (18.3) 89 (81.7) 48 (44)
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Cerebral control of micturition
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Classification of NVD-- Krane Siroky 1979

• Detrusor hyperreflexia
• Coordinated sphincter
• Striated sphincter dyssynergia
• Smooth muscle sphincter (BN) dyssynergia
• Detrusor areflexia
• Coordinated sphincter
• Non-relaxed striated sphincter
• Denervated striated sphincter
• Non-relaxing smooth muscle sphincter (BN)

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Sphincter corrdination in Neurogenic Voiding
Dysfunction
Coordinated Non-relaxing Poor relaxed Dyssynergia
?.Intracraniall Lesion (n141) 99 (70.2) 10 (7.1) 23 (16.3) 9 (6.2)
?.SCI (n195)
Cervical (78) 5 (6.4) 7 (9) 9 (11.5) 65 (83.3)
Thoracic (69) 4 (2.9) 22 (15.9) 10 (7.2) 37 (53.6)
Lumbar (25) 2 (8) 11 (44) 5 (20.0) 8 (23)
Sacral (23) 0 (0) 8 (34.8) 7 (30.4) 8 (34.8)
?.Cauda equina lesion (n17) 1 (5.9) 9 (52.9) 7 (41.2) 2 (11.8)
?.Peripheral neuropathy (n57) 24 (42.1) 22 (38.6) 11 (19.3) 1 (2)
?.DM (n109) 58 (53.2) 16 (14.7) 26 (23.9) 11 (10.1)
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Urinary tract Abnormalitie Neurogenic Voiding
Dysfunction
Trabeculation Bladder VUR Hydronephrosis BOO
?.Intracraniall Lesion (n141) 31 (22) 1 (7.1) 4 (2.8) 61 (43.3)
?.SCI (n195)
Cervical (78) 27 (34.6) 3 (0.7) 9 (11.5) 57 (73.1)
Thoracic (69) 19 (27.5) 3 (3.8) 14 (20.3) 38 (55.1)
Lumbar (25) 3 (12) 1 (4.3) 5 (20) 15 (60)
Sacral (23) 7 (30.4) 1 (4) 2 (8.7) 11 (47.8)
?.Cauda equina lesion (n17) 3 (17.6) 0 (0) 0 (0) 3 (17.6)
?.Peripheral neuropathy (n57) 10 (17.5) 3 (5.3) 6 (10.5) 19 (33.3)
?.DM (n109) 20 (18.3) 1 (0.9) 8 (7.3) 32 (29.4)
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Micturition reflex and Nervous pathways
??????PONS
???T10-L2
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??S2,3,4
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Stroke

• Initial retention, bladder neck is closed
• Detrusor hyperreflexia incontinence
• Continence reappears by 6 Mo in 80
• Irritative LUTS DH
• Dysuria and obstructive LUTS DHIC,BPO, poor
  relaxation of external sphincter (frontoparietal
  internal capsule lesion)
• Subcortical lesion areflexia, retention (47)
• Areflexia in 85 hemorrhage, 10 ischemia

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Stroke and Bladder outlet obstruction

• Detrusor hyperreflexia in 82 after stroke,
  obstruction was noted in 63
• Pseudodyssynergia may be a urodynamic finding for
  obstructive symptoms
• Incidence of BOO is equally distributed in
  patients with irritative and obstructive LUTS
• Prostatectomy should not be done in 1 year after
  stroke

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Detrusor areflexia at initial stage of Stroke
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Prostatic obstruction in Stroke
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Pseudodyssynergia in Stroke
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Intracranial Diseases and NVD

• Cerebral vascular accidents DH
• Parkinsons disease DH, ext. sphincter
  pseudodyssynergia
• Cerebellar ataxia DH, DESD
• Cerebral palsy normal voiding, DH
• Dementia DH, DHIC, DA
• Recurrent stroke DH,DHIC, DA

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Urodynamic findings in ICD

• Detrusor hyperreflexia lack of inhibitory
  effect
• Detrusor areflexia initial post-stroke period,
  failure of initiation ability in chronic case
• Decreased ability in initiation at small voided
  volume -- hesitancy
• Decreased ability of voluntary sphincter
  contractions -- incontinence
• Sphincter coordination is normal no DESD
• Normal detrusor pressure, low/normal flow

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Development of Low Compliance bladder after CVA
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Recovery of detrusor contraction after stroke
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Multiple Sclerosis

• Detrusor hyperreflexia occurs in 60-70, DESD in
  20-40, hypocontractility in 15-40
• Lower urinary tract dysfuncton affect 80 of MS
  patients, rising to 96 after 10 years of MS
• Symptoms wax and wan
• Incontinence dysuria the main LUTS

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DESD in Multiple Sclerosis
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Diabetes mellitus

• Detrusor hypocontractility in 35
• Detrusor hyperreflexia in 55-60
• Detrusor areflexia in chronic DM
• Increased incidence of bladder outlet obstruction
  in chronic cases
• When TURP is attempted, prostatic obstruction
  should be confirmed by videourodynamic study

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Low Detrusor Contractility in Diabetes Patient
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Parkinsons Disease

• Detrusor hyperreflexia and frequency urgency
• External sphincter pseudodyssynergia results in
  poor relaxation and difficult initiation of
  voiding
• DHIC in severe case
• Symptoms wax and wan with treatment

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DHIC in Parkinsons disease
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Detrusor hyperreflexia with BPO in Parkinsons
disease
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Other conditions

• Transverse myelitis sudden onset of dysuria and
  retention, reversible, DH, DESD,DA can be found
  in urodynamics
• In 39 HIV positive patients 87 had urodynamic
  abnormality 62 due to toxoplasmosis
  encephalitis and DH, half of them could recover
  after treatment

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Bladder neck dysfunction and DESD in Spinal cord
lesion
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DESD and low contractility in Incomplete Cervical
SCI
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Management of NVD following stroke and ICD

• Indwelling Foley catheter in initial stage
• Clean intermittent catheterization
• Urodynamic test after recovery of motor function
• Avoid bladder overdistention to 500ml
• Trocar cystostomy in male patients
• Alpha-blocker and urecholine therapy

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Clean intermittent (self) catheterization (CIC,
CISC)

• Easy to perform when properly instructed
• Adequate lubrication is necessary
• Will not exacerbate UTI occurrence
• Bladder capacity and intravesical pressure should
  be determined before institution of CIC

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Clean Intermittent Catheter
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Indwelling catheter andTrocar cystostomy

• Easy to care in debilitative patients
• Frequent exchange of catheter is needed
• Stone formation and symptomatic UTI
• Contracted bladder and VU reflux
• Fecal soiling in female patients
• Surgical complication in trocar cystostomy
• Mucosal dysplasia and bladder cancer

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Trocar Cystostomy
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Advantage and disadvantages of Trocar cystostomy

• Facilitate voiding training
• Free of genital tract infection
• Free of fecal soiling in women
• Minimally invasive procedure
• Regular local treatment and replacement
• Risk of bowel perforation
• Granuloma formation around catheter

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Medical Treatment

• Increase detrusor muscle tone -- bethanechol
• Decrease detrusor hyperreflexia oxybutynin,
  tolterodine, imipramine, flavoxate, dicyclomine
• Decrease outlet resistance alpha-adrenergic
  blocker, skeletal muscle relaxant, nitric oxide
  donors
• Increase outlet resistance methylephedrine,
  imipramine

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Medical treatment for detrusor instability
inadequate contractility

• Existence of bladder outlet obstruction
• Residual urine amount
• Patients ability of abdominal straining
• Patients ability of performing CISC
• General condition
• Adjust combination of anticholinergics and
  alpha-blocker

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Intravesical therapy for DH

• Intravesical oxybutynin (ditropan)
• Electromotive treatment of oxybutynin
• Resiniferatoxin therapy (10-6 -7M RTX)
• Detrusor injection of botulinum toxin 200-300
  IU Botox or 500 U Dysport injected to detrusor
  muscles at 20-30 sites

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Effects of resiniferatoxin in DH
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Idiopathic Detrusor failure

• Occult neuropathy or myopathy
• Detrusor underactivity in the elderly
• Urinary retention developed after major surgery
  or diseases
• Bladder overdistention during TURP or major
  surgery
• Recovery takes time maybe 3-6 months

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Idiopathic Detrusor Instability Underactivity
after Surgery
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Treatment of idiopathic NVD

• Search for bladder outlet obstruction
  Peripheral neuropathy, especially in old women
• CISC or trocar cystostomy
• Urecholine alpha-blocker
• Try nitric oxide donors to facilitate void
• Periurethral botulinum toxin injection 50- 100
  units to avoid catheterization

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Botulinum A toxin
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Botulinum A Toxin Injection in Woman
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Cystoscopic Urethral Injection in Men




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Reduced abdominal voiding pressure after
botulinum toxin
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Recovery of detrusor contractility in detrusor
underactivity
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Surgical treatment for NVD

• TURP in male and TUI-BN in women with NVD due to
  definite bladder outlet obstruction
• External sphincterotomy in quadriplegia and
  chronic debilitative patients
• Intraurethral stent for high risk patients
• Urinary diversion

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BPO in a Man after Stroke
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Urinary incontinence exacerbates after TURP in DH
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Considerations in management of neurogenic
voiding dysfunction

• Lower urinary tract dysfunction changes with time
• Avoid overdistention and recurrent cystitis
  during recovery period
• Avoid unnecessary surgery
• Regular urodynamic follow-up and determine proper
  volume in CIC
• Do not abandon patients with NVD

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Improved Detrusor contractility after acute Stroke