Neurogenic Voiding Dysfunction

1. Neurogenic Voiding Dysfunction Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. 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

3. 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

4. Treatment of NVD • Based on pathophysiology of NVD • Patient’s self-handling capability • Family support • Convenience of medical care • Patient’s will of management

5. Neurogenic Voiding Dysfunction (1997-2002)

6. Symptomatology of Neurogenic Voiding dysfunction

7. 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

8. Normal Micturition

9. 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

10. Diagram of Micurition reflex

11. 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

12. Urodynamic Classification NVD • Sacral cord lesion – detrusor areflexia with non-relaxing urethra; atonic urethra • Peripheral neuropathy – detrusor areflexia with discoordinated urethral sphincter

13. Urodynamic findings in Neurogenic Voiding dysfunction

14. Cerebral control of micturition 大腦前葉 小腦 橋腦排尿中樞

15. 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)

16. Sphincter corrdination in Neurogenic Voiding Dysfunction

17. Urinary tract Abnormalitie Neurogenic Voiding Dysfunction

18. Micturition reflex and Nervous pathways 橋腦排尿中樞PONS 胸腰髓T10-L2 薦髓 薦髓S2,3,4 骨盆底神經 陰部神經

19. 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

20. 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

21. Detrusor areflexia at initial stage of Stroke

22. Prostatic obstruction in Stroke

23. Pseudodyssynergia in Stroke

24. Intracranial Diseases and NVD • Cerebral vascular accidents – DH • Parkinson’s disease – DH, ext. sphincter pseudodyssynergia • Cerebellar ataxia – DH, DESD • Cerebral palsy – normal voiding, DH • Dementia – DH, DHIC, DA • Recurrent stroke – DH,DHIC, DA

25. 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

26. Development of Low Compliance bladder after CVA

27. Recovery of detrusor contraction after stroke

28. 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

29. DESD in Multiple Sclerosis

30. 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

31. Low Detrusor Contractility in Diabetes Patient

32. Parkinson’s 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

33. DHIC in Parkinson’s disease

34. Detrusor hyperreflexia with BPO in Parkinson’s disease

35. 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

36. Bladder neck dysfunction and DESD in Spinal cord lesion

37. DESD and low contractility in Incomplete Cervical SCI

38. 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

39. 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

40. Clean Intermittent Catheter

41. 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

42. Trocar Cystostomy 導引器外套 膀胱 前列腺 直腸

43. 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

44. 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

45. Medical treatment for detrusor instability & inadequate contractility • Existence of bladder outlet obstruction • Residual urine amount • Patient’s ability of abdominal straining • Patient’s ability of performing CISC • General condition • Adjust combination of anticholinergics and alpha-blocker

46. 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

47. Effects of resiniferatoxin in DH

48. 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

49. Idiopathic Detrusor Instability & Underactivity after Surgery

50. 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