Recent Advances in Management of the Neurogenic Voiding Dysfunction

1. Recent Advances in Management of the Neurogenic Voiding Dysfunction Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. Neurogenic Voiding Dysfunction (1997-2002)

3. Neurogenic voiding dysfunction • Failure to store – Detrusor hyperreflexia Urethral incompetence • Failure to empty – Detrusor areflexia Bladder neck dysfunction, BPO, External sphincter dyssynergia Combined failure to store and empty – DESD, DHIC

4. Symptomatology of Neurogenic Voiding dysfunction

5. Urodynamic findings in Neurogenic Voiding dysfunction

6. Urinary Tract Abnormalities in Neurogenic Voiding Dysfunction

7. Pseudodyssynergia in Stroke

8. DESD in Multiple Sclerosis

9. Detrusor external sphincter dyssynergia in cervical SCI

10. Bladder neck dysfunction and DESD in Spinal cord lesion

11. Medication for Detrusor hyperreflexia • Oxybutynin & anticholinergics • Imipramine • Intravesical capsaicin & resiniferatoxin • Intra- detrusor botulinum toxin • Multiple medication increases adverse effect especially in elderly with inadequate detrusor contractility (DHIC)

12. Medication for Bladder outlet obstruction • Bladder neck – alpha-adrenergic blocker • Smooth muscle – Nitric oxide donors (nitroglycerine, isosorbid mononitrate), anticholinergics • Striated muscle – baclofen, diazepam, dantrolene, calcium channel blocker, NO donors, botulinum A toxin • Enlarged Prostate – finasteride (Proscar)

13. Priority of Management of Neurogenic voiding dysfunction • Preservation of renal function • Freedom of urinary tract infection • Efficient bladder empty • Freedom of indwelling catheter • Achievement of urinary continence • Patient’s will of management • Avoid medication after management

14. Reduced frequent detrusor contractions after Oxybutynin

15. Tolterodine vs Oxybutynin • A secondary amine with competitive muscarinic receptor blocking property • As potent as oxybutynin in inhibiting detrusor contractions • 8 times less potent in inhibiting salivation than oxybutynin • 2mg bid tolterodine in comparison to 5mg tid of oxybutynin • Titration doses from 1-2 mg bid to 4mg bid

16. Side effects of Anticholinergic • Post-synaptic receptors M1 and M2 are widespread in CNS, anticholinergics may have cognitive dysfunction, especially in elderly • Dry mouth, constipation, blurred vision • Darifenacin has 11-fold higher affinity to M3 than M2 receptors and a 5-fold lower affinity for M receptors in parotid gland

17. Pharmacology of Detrusor Overactivity

18. Extended-release system for oxybutynin & tolterodine

19. Electrostimulation and electromodulation for NVD • Detrusor contractility reduces during electrostimulation of pelvic floor • Detrusor overactivity – Sacral neuromodulation, Surface sacral electromagnetic current stimulation • Detrusor underactivity – Sacral nerve or Intravesical neurostimulation

20. Implantation of Sacral Stimulator

21. Correct placement of electrode on Sacral nerves

22. Surgical Treatment for Neurogenic Voiding Dysfunction • Detrusor hyperreflexia – Augmentation cystoplasty Bladder autoaugmentation Sacral posterior root rhizotomy • Detrusor areflexia – TUI-bladder neck, TUR-prostate External sphincterotomy Urethral stent

23. Surgical technique of augmentation cystoplasty

24. Abdominal straining to void after Enterocystoplasty

25. Bladder Autoaugmentation

26. Seromuscular enterocystoplasty

27. Technique of Sphincterotomy • 12 o’clock position • Incision from BN to bulbous • Cutting deep to fat & vessel • Bleeding can be controlled • Avoid diffused coagulation • On Foley catheter for 2 days

28. Urethral Stent Implantation

29. Surgical procedures for Neurogenic urethral incontinence • Pubovaginal sling procedure for women • Periurethral collagen or Teflon injection for urethral sphincteric deficiency • Combined urethral augmentation (by collagen or Teflon) with bladder augmentation • Artificial sphincter implantation • Closure of bladder outlet and continent cystostomy using appendix or ileum

30. Pubovaginal sling procedure for Urethral incontinence

31. Periurethral Teflon injection in SCI with urethral relaxation

32. Intravesical Therapy for Detrusor overactivity • Blocking efferent cholinergic fibers – intravesical oxybutynin, atropine • Blocking neuromuscular junction – intravesical botulinum A toxin injection • Blocking afferent fibers that mediate detrusor reflex – intravesical lidocaine • Blocking C-fiber mediated detrusor contractions – intravesical capsaicin, resiniferatoxin

33. Treatment of DH & Reduced Detrusor Contractility after Capsaicin therapy

34. Therapeutic Effects of Resiniferatoxin on Detrusor Overactivity • 10 -5 to 10 -7 M RTX is effective for DH of SCI and DH of CNS origin • 10 -8 M RTX can significantly improve voiding pattern and pain score in hypersensitive disorders and bladder pain • RTX is safe for application in humans • Less initial irritative response in RTX treatment than capsaicin

35. Initial Response of RTX therapy

36. Urodynamic Result after RTX Therapy in a SCI patient

37. Urodynamic Changes after RTX in Chronic SCI with DESD

38. Intravesical RTX in treatment of Neurogenic Detrusor Overactivity • C-fiber mediated detrusor reflex does not predominate neurogenic detrusor overactivity in lesion above pons • Resiniferatoxin in 10-6~-7 M can activate initial excitatory responses • Therapeutic results are not as satisfactory as that in SCI patients • An alternative for patients who cannot tolerate or refractory to anticholinergic agents

39. Urodynamic results after RTX therapy in Neurogenic detrusor overactivity

40. Therapeutic Results of RTX in Neurogenic v Non-neurogenic Voiding Dysfunction • 22/41 patients (53.6%) with detrusor overactivity improved after RTX 10-7M instillation (initial concentration) • 6/10 (60%) Neurogenic DH, 4/13 (31%) Idiopathic DI, 12/18 (67%) BOO related DI improved 6/7 (86%) type I, 1/3 (33%) type II, 7/16 (44%) type III, 8/15 (53%) type IV

41. Urodynamic Changes after RTX in Detrusor Overactivity

42. Botulinum A toxin Injection • Inhibition of acetylcholine (Ach) release from presynaptic cholinergic fiber • Induce paralysis of muscle fibers • Intravesical injection can inhibit detrusor overactivity • Urethral injection can reduce urethral resistance and sphincter spasticity • Duration of effect about 3-6 months

43. Transurethral injection of Botulinum A toxin in male urethral sphincter * * * *

44. Injection of 3,6, 9, and 12 o’clock Position of Urethral Sphincter

45. Reduced voiding pressure after botulinum A toxin injection

46. Reduced MUCP after Botulinum A toxin injection

47. Table 1.The Urodynamic Parameters at Baseline and after Botulinum Toxin in Effective Patients MUCP=maximal urethral closure pressure, FPL=functional profile length, PVR= postvoid residual volume *Comparison between baseline and 4weeks after treatment

48. Therapeutic Results after Botox Urethral Injection for Voiding Dysfunction DESD=Detrusor external sphincter dyssynergia

49. Botulinum Toxin Detrusor Injection for Detrusor Hyperreflexia

50. Btulinum A Toxin Detrusor Injection for DH