M

Detrusor hyperreflexia in a 54 year old woman with exacerbating & remitting multiple sclerosis. (A) Urodynamic tracing. At a bladder volume of 165 ml there was an involuntary detrusor contraction (arrow) which reached a maximum of 100 cm H20 (during sphincter contraction). Qmax 13 ml S and 25 cm H20. Throughout the detrusor contraction, there was increased EMG activity as she tried to abort the detrusor contraction. When she relaxed, (at Qmax) there was complete EMG silence....

Spontaneous Perforation

Spontaneous perforation following cystoplasty is not an uncommon occurrence and is being reported more frequently in the literature. It is important to consider this diagnosis following cystoplasty in those patients who may have signs and symptoms of an acute abdomen as it is a potentially lethal complication of enterocystoplasty. The incidence is reported to be between 3-6.1 (36,37). The diagnosis should be prompted by a very high index of suspicion, and many times the diagnosis may be...

Preoperative Evaluation

The preoperative surgical evaluation should include a thorough history and physical examination to determine the underlying etiology of the bladder dysfunction, as well as laboratory, radiographic, endoscopic, and urodynamic studies. It is largely upon these results that the surgeon will decide whether the patient requires augmentation or substitution cystoplasty and what appropriate management of the ureters and outlet should be. The preoperative laboratory evaluation is necessary to assess...

Index

Abdominal examination, 31 Abdominal leak-point pressure (ALPP), 45-46 Abdominal stoma, 100 Abdominal straining voiding, 210 Abrams-Griffiths Nomogram, 47f Absent volitional control of the external sphincter (AVCS), 68, 69t Acetylcholine (Ach), 276, 281-282 Acontractile bladder female urinary retention, 204 Acquired immune deficiency syndrome (AIDS) female urinary retention, 205 Activities of daily living (ADL) female urinary retention, 207 209 AIDS female urinary retention, 205 Alcohol...

Disrupted Micturition Balance

Conscious control allows voiding to occur at convenient times. Inhibitory reflexes (autonomic and somatic) coordinated by the pons are needed to keep the sacral micturition reflex in balance. If these reflexes are overly inhibited, the balance is tipped towards urgency and urge incontinence. If they are overly facilitated, the balance is shifted towards urinary retention. Viewed in this way, detrusor instability and urge incontinence simply represent the flip side of urinary retention. Both...

Summary

Lower urinary tract symptoms in patients afflicted with MS are very common. In general, treatment should be predicated on a clear understanding of the underlying pathophysiology, and for most patients, this means that urodynamic studies should be part of the evaluation. Because of the unpredictable course of MS, therapy should commence with the least invasive. Ablative or irreversible surgery should be reserved for patients with stable or progressive disease who have no reasonable hope for...

References

Wein A J (1981) Classification of neurogenic voiding dysfunction. J Urol 125 605607. 2. Diokno AC, Brock BM, Brown MB, et al. (1986) Prevalence of urinary and other urologic symptoms in the non-institutionalized elderly. J Urol 136 1022-1025. 3. Abrams P (1994) New words for old lower urinary tract symptoms for prostatism. Br Med J 308 929. 4. Blaivas JG, Heritz DM (1996) Classification, diagnostic evaluation and treatment overview. In Topics in Clinical Urology Evaluation and Treatment of...

Sacral Nerve Stimulation

Sacral nerve stimulation (SNS) therapy acts on the neural reflexes of the bladder at the level of the S3 sacral nerves. The therapy is based on conclusions from animal experimentation and electrophysiologic studies that electrical stimulation of sacral nerves can modulate neural reflexes that influence bladder, sphincter, and pelvic-floor behavior (8,14,15,18,34) (see Fig. 2). The effects of SNS depend on the electrical stimulation of afferent axons in the spinal roots, which in turn modulate...

Evaluation of the Male Bladder Outlet

Lower urinary tract symptoms in men were previously thought to be caused by benign prostatic hyperplasia. However, it is now known that a variety of conditions can cause such symptoms, including bladder outlet obstruction, detrusor instability, and impaired detrusor contractility. Cystoscopic evaluation of men with LUTS used to be routine however, now its indications are more limited. Based on the available evidence and world literature, The World Health Organization Third International...

Pathophysiology

The cause of the bladder dysfunction seen in DM is primarily the result of peripheral and autonomic neuropathy. The classic diabetic cystopathy has been attributed to diminished sensation leading to a chronically overstretched bladder, which results in myogenic failure and the inability to mount a satisfactory detrusor contraction. The findings of detrusor instability in a significant number of patients implies that the cortical or spinal regulatory tracts can be affected too. In diabetes,...

History

The patient's history is the first step in directing the clinician toward the appropriate evaluation and treatment. It should provide the clinician with a detailed account of the precise nature of the patient's symptoms. It is important to remember that the history is only as accurate as the patient's ability to describe their symptoms, therefore, some skill is required by the physician to obtain this information. This is especially true for patients who have difficulty communicating or those...

Physical Examination

A complete physical exam is important however, certain aspects of the exam need to be emphasized. A focused physical examination should be performed to 1. Assess the bladder for masses and fullness 2. Assess the external genitalia 3. Assess the pelvic floor, including anal sphincter tone, and thoroughly examine for support defects, prolapse, and other pelvic conditions in women 5. Demonstrate incontinence in patients with that symptom 6. Detect neurologic abnormalities that may contribute to...

Medications for Inflammatory Conditions of the Bladder Causing Storage Failure

Interstitial cystitis (IC) is a syndrome whose pathogenesis and etiology remain a mystery. Even the diagnosis of this entity is difficult and considered one of exclusion. There are four currently proposed etiologies for this syndrome inflammation, vascular insufficiency, epithelial leak, and deficiency of proteoglycans (i.e., glycosaminoglycans-GAG-). Dimethysulfoxide (DMSO), after being approved for use in 1977, has been shown to induce remission in 35-40 of the patients (128) and is a...

Spinalcord Injuries

The major causes of spinal-cord injury during peacetime are motor vehicle accidents, diving accidents, and falls. Other causes include disc prolapse, acute myelitis, surgery of thoracic aortic aneurysms, and occasionally aortography (15,16), Over 12,000 new cases of traumatic, spinal-cord injury occur each year in the United States, with an incidence estimated at 32 new injuries per million annually and a prevalence of 906 cases per million (17). Eighty-five percent of all cases are in men. The...

Transvaginal Denervation Ingelmannsundberg Procedure

In 1959, Ingelman-Sundberg described a transvaginal technique intended to accomplish partial denervation of the subtrigonal nerve supply to the bladder. He reported an 88 success rate in 34 women with urinary frequency, urgency, urge incontinence, and bladder pain. A subsequent series corroborated these results and cited a 6-15 recurrence rate in the two series (55). Several other authors cited success rates of about 50 (56). Wan and McGuire, in an abstract, reported that 72 of 62 patients were...

Medications to Facilitate Bladder Emptying

Normal detrusor contractions can be inhibited by any alteration in the neuromuscular mechanism that is responsible for initiating and maintaining micturition. These can result from spine injuries, neurologic diseases, or events such as pelvic perineal pain, psychogenic problems, and myogenic impairment that influence the nociceptor reflex mechanisms. Ach results in bladder contractions via the parasympathetic nervous system, but it cannot be used as a medication because it is rapidly broken...

Neuropathophysiology

A review of the relevant neuroanatomy is necessary before discussing the neuropathology resulting from lumbar disc disease. Innervation of the lower urinary tract is derived from both the autonomic and somatic nervous systems. The parasympathetic pelvic nerves, From Current Clinical Urology Voiding Dysfunction Diagnosis and Treatment Edited by R. A. Appell Humana Press Inc., Totowa, NJ Innervation of the Lower Urinary Tract Parasympathetic (Pelvic nerve) S2-S4 Tension receptors in bladder wall...

Urodynamics

Urodynamics is the study of the transport, storage, and evacuation of urine by the urinary tract. It is comprised of a number of tests that individually or collectively can be used to gain information about lower urinary tract function and can provide a precise diagnosis of the etiology of voiding dysfunction. However, in order to use urodynamics in a practical and effective way, it is important for the clinician to know when and why a urodynamic investigation should be performed. There are...

Augmentation Cystoplasty With Without Continent Catheterizable Abdominal Stoma And Continent Urinary Diversion

We believe that augmentation cystoplasty is the treatment of choice for MS patients with refractory detrusor hyperreflexia and or low bladder compliance (77,78,79,80). However, it should only be considered when all conservative measures have failed in patients who are able and willing to accept permanent intermittent self catheterization should that prove necessary. A continent urinary diversion or augmentation cystoplasty with a continent abdominal stoma is especially useful for female...

Serge Peter Marinkovic MD and Gopal H Badlani MD

Of the Lower Urinary Tract and the Pontine Micturition Center (PMC) Incidence of Urinary Incontinence Pathophysiology of Incontinence Early Presentation Late Presentation Urodynamics Studies Hemispheric Dominance and Voiding Dysfunction Urological Evaluation History Technical Difficulties Interpretation of the Study Specific Situations Medical and Surgical Management Urinary Retention in Women Urinary Incontinence in Men and Women Alternative Therapies Summary References From Current Clinical...

Pregnancy After Bladder Reconstruction

Pregnancy following enterocystoplasty is becoming more common as women who undergo bladder reconstruction for congenital problems enter their childbearing years. These women during their pregnancy could potentially have significant morbidity including febrile urinary infections, premature labor, urinary tract obstruction, and compromised renal function. Renal function should be monitored vigilantly in these women with monthly serum creatinines and, when indicated, renal ultrasonography. Hill...

Behavioral Voiding Dysfunction Pseudodyssynergia

Bladder outlet obstruction may also occur in the setting of an anatomically normal male patient owing to a dynamic obstruction caused by a lack of coordination between the detrusor and bladder neck smooth muscle (bladder neck dyssynergia) or striated muscle external sphincter (pseudodyssynergia). While psydodyssynergia generally implies a condition in a neurologically intact patient, similar conditions may be the result of a neurologic lesion (detrusor external sphincter dyssynergia, DESD) or...

Urological Evaluation

The 1990s have seen the implementation of a multidisciplinary approach to the evaluation of the strokes (39). Neurologist, internist, and psychiatrist play key roles, whereas the urologist is consulted as needed. Our knowledge of voiding dysfunction in stroke patients largely comes from the evaluation of only symptomatic patients. In most instances, urological evaluation begins when the patient is transferred from an acute-care facility to a rehabilitation or a stroke unit. Like any other...

Transurethral Resection of the Prostate and Open Prostatectomy

Prostatectomy

In many cases, prostatic hypertrophy extends beyond the verumonta-num (25,26) (Fig. 2). Thus, the verumontanum remains a critical landmark when performing a transurethral prostatectomy. If the resection is carried past the vera, violation of the distal urethral sphincter will occur, resulting in postoperative incontinence. The distal limit of resection should be at the verumontanum, even if a small rim of adenoma is left behind. This small amount of adenoma may provide some protection against...

Anatomic Obstructive

Gynecologic Causes of Bladder Outlet Obstruction Gynecologic causes of voiding dysfunction arise from angulation or distortion of the proximal urethral and bladder neck caused by periurethral or perivesical gynecologic lesions. The most common gynecologic cause of outlet obstruction is that resulting from large cystocele formation. Cystocele formation results in acute kinking or angulation of the proximal urethra and bladder neck in relationship to the bladder base. The patient will often...

Longterm Urologic Management

In order to best manage a patient with voiding dysfunction caused by a spinal-cord lesion or injury, it is important to consider the patient's age, sex, level of lesion, degree of ambulation, manual dexterity, and independence. On the basis of both the clinical and urodynamic evaluation, as mentioned previously, urinary bladder symptoms may be classified as filling storage abnormalities, emptying abnormalities or a combination of these (14,19), and treatment can be directed at the underlying...

Simple Tests For Evaluating Voiding Dysfunction

Uroflow Normal

When history and physical cx3.i 1 alone are insufficient to make a diagnosis or institute treatment, or when more objective information is desired, the clinician may start with simple tests to evaluate lower urinary tract function. These are noninvasive or minimally invasive placement of a urethral catheter tests that can provide information that may influence treatment or further diagnostic evaluation. The most basic of these include a voiding and intake diary, measurement of postvoid residual...

Classification Of Voiding Dysfunction

The purpose of any classification system should be to facilitate understanding and management. A good classification should serve as intellectual shorthand and should convey, in a few key words or phrases, the essence of a clinical situation. An ideal system for all types of voiding dysfunction would include or imply a number of factors 1. the conclusions reached from urodynamic testing 3. the approximate site and type of a neurologic lesion, or lack of one. If the various categories accurately...

Anatomy Of The Prostate Gland And Urinary Sphincter

Verumontanum

The prostate gland is comprised of three glandular zones and one nonglandular region, the anterior fibromuscular stroma. The three glandular regions arise from different segments of the prostatic urethra 13 . The transition zone constitutes about 5 of prostatic glandular tissue and is located on both sides of the prostatic urethra. It is in this zone that benign prostatic hyperplasia develops 14 . The transition zone is separated from the central and peripheral zones of the prostate by the...

Followup Prevention Of Complications

Annual urologic follow-up is necessary in all patients with spinalcord injury or myeloneuropathies, regardless of the nature or ease of bladder management. In fact, approx 40 of all SCI patients would die of renal insufficiency if they were left completely untreated 75,76 . The evaluation should rule out any chronic, symptomatic infection of the urinary tract or urolithiasis and include an upper urinary tract assessment with either an intravenous pyelogram or renal ultrasound. There is...

Sphincteric Incompetence

Doing Kegels With Catheter

Pelvic-floor muscle exercises called Kegel exercises can speed the recovery of continence following prostatectomy therefore, patients should be instructed and perform the exercises before prostatectomy 55 . There are several studies which suggest the utility of electrical stimulation 56 , behavior training 57 , and biofeedback 58 in the management of incontinence after prostate surgery. Unfortunately, many of these studies contain only a small number of patients, and many patients still...

Carney Enterocystoplasty

Von Mikulicz J 1899 Zur Operation der angeborenen Blasenspalte. Zentralbe Chir 20 641-643. 2. Kuss R, Bitker M, Carney M, et al. 1970 Indications and early and late results of intestinocystoplasty a review of 185 cases. J Urol 103 53. 3. Couvelaire R 1950 La petite vessie des tuberculeux geniourinaires essai de classification pacelore et variantesioute des cysto-intestine-plasties. J Urol Paris 56 381. 4. Gil-Vernet JM 1965 The ileocolic segment in urologic surgery. J Urol 94 418. 5. Pitts...

Detrusor Myotomy Bladder Transection And Cystolysis

Bladder transection cystocystoplasty was introduced for the treatment of patients with refractory detrusor instability by Turner-Warwick and Ashken in 1967 68 . The procedure is essentially a circumferential bladder transection with immediate reconstruction. An incision was made through the full thickness of the bladder wall and perivesical tissue between a point 1 to 2 cm. lateral to each ureteral orifice. The incision through the bladder wall is then closed in 1 layer with absorbable suture...

Transvaginal and Transanal Electrical Stimulation Devices

Noninvasive electrical stimulation of the pelvic floor using an externally applied electrical source offers potential for retraining the basic physiologic responses of intact muscle tissue for patients with stress, urge, or mixed incontinence. Electrical stimulation induces a Kegeltype movement of the pelvic floor muscles and therefore may be useful Comparative Overview of Electrical Stimulation Therapies for Urinary Incontinence Clinical Application Treatment Regimen Transvaginal and transanal...

Detrusor Areflexia

Intermittent self catheterization is the simplest and most effective means of managing patients with detrusor areflexia. Over time, though, some of these patients develop low bladder compliance or detrusor hyperreflexia that requires a change in management 95,15 . There is no proven pharmacologic therapy for detrusor areflexia. Bethanechol chloride is, in our experience, ineffective for the treatment of detrusor areflexia. Although bethanechol can raise intravesical pressure, this does not...

Contraindications To Augmentation Cystoplasty

There are relatively few contraindications to cystoplasty. Compromised renal function in the past was initially considered an absolute contraindication to bladder reconstruction as it could exacerbate metabolic problems owing to the absorptive surface of the bowel within the urinary tract. However, if the etiology of the underlying renal impairment is owing to hostile detrusor function, then augmentation cystoplasty may stabilize or improve renal function. It is of utmost importance to counsel...