Mechanism Of Action Of Electrical Stimulation

The way in which electrical stimulation improves voiding dysfunction is unknown, but most experts agree that the therapies work by producing a modulatory effect on sacral nerve reflexes (5-10). Stimulation restores a balance between sacral reflexes that are either overly inhibited or facilitated. Depending on where the stimulation is delivered, the mechanism and potential benefit may be different. For example, transvaginal or transanal devices first stimulate skin receptors and myelinated...

Voiding Difficulties

It is not unusual for patients to experience voiding difficulty or incomplete bladder emptying after bladder reconstructive procedures particularly in those undergoing an outlet procedure. Preoperatively these patients should understand that clean intermittent self-catheteriza-tion may be necessary to allow for complete bladder emptying. Neuro-logically intact patients undergoing clam augmentation cystoplasty usually void efficiently following bladder reconstructive surgery. Those...

The Sphincter Stent

Endoluminal urethral stent prostheses have recently been used as an alternative treatment for DESD. Several intraurethral stents are currently available, but only the UroLumeTM (American Medical Systems, Minnetonka, MN) has been systematically tested in the membranous urethral for the treatment of DESD. The Multicenter North American Trial data of 153 patients treated with the sphincter stent has shown promising results (94). The efficacy of the stent prosthesis approximates that of external...

Neurogenic Functional

Chronic manifestations of diabetes mellitus (DM) affect the lower urinary tract in both sexes. Often in diabetics, cystopathy is associated with demonstrable peripheral neuropathy in the patient who has insulin-dependent diabetes mellitus (IDDM). Diabetes is associated with segmental neuronal demyelination, axo-nal degeneration, and peripheral nervous system degeneration of the autonomic and somatic nervous systems in the affected population (16,17). It has been previously shown that...

Concurrent Stress Incontinence

In some patients with MS, particularly those with conus medullaris lesions, there is weakness and denervation of the pelvic floor striated sphincter muscles leading to sphincteric incontinence (95,96). Others have sphincteric incontinence because of anatomic abnormalities unrelated to MS. In either case, there are many effective surgical treatments for sphincteric incontinence. However, because of the unpredictable nature of MS, there is probably a higher incidence of urinary retention and...

T XJuALXvIOSi Of Postprostatectomy Incontinence

As with all clinical situations, the evaluation of postprostatectomy incontinence begins with a complete history and physical examination. The history should include detailed information about the urinary leakage. When did the leakage occur after surgery, and was any leakage present prior to surgery The events occurring during leakage (activity, urgency or no sensation) as well as associated urinary symptoms (force of stream, complete emptying) are important factors. Day and nighttime pad usage...

Extraurethral Incontinence

Endoscopy can be an invaluable tool in the diagnosis and treatment of extraurethral incontinence due to vesicovaginal fistula and ectopic ureter. Cystourethroscopy can precisely localize a fistula site in the bladder and help plan surgical correction. Occasionally, a small fistula that is not seen on physical exam or by radiographic studies can be diagnosed only by cystoscopy. Incontinence owing to ectopic ureter in the female is usually diagnosed by radiographic studies. However, the exact...

Central Innervation Of The Lower Urinary Tract And The Pontine Micturition Center

The central nervous system (CNS) has an important role in regulating the ability of the bladder to facilitate the storage and emptying of urine. These CNS functions may be divided into three specific areas suprapontine, pontine, and spinal centers. Voiding is coordinated by the neurons of the pontine-mesencephalic gray matter or the Pontine Micturition Center (PMC) (17,18). Voiding depends on the spinobulbospinal reflex through the PMC after receiving input from the hypothalmus, thalmus, basal...

Artificial Urinary Sphincter

If the goal of surgical treatment is to establish a normal voiding pattern that allows the patient to remain dry between voiding, then the artificial urinary sphincter is one of the best treatment options capable of achieving this result. The artificial urinary sphincter is intended to permit intermittent urethral compression for maintaining continence with voluntary reduction of urethral resistance during voiding, as opposed to other surgical procedures in which the compressive nature of...

Lower Urinary Tract Imaging

When anatomical factors are considered as a possible cause of voiding dysfunction, lower urinary tract imaging can be useful. A plain radiograph of the abdomen and pelvis (KUB) can determine the presence of stones or foreign bodies, which can be contributing to LUTS and voiding dysfunction. The lower spine can also be evaluated (spina bifida occulta or sacral agenesis). A cystogram, with stress and oblique views, can be useful in select cases of pelvic prolapse (especially when the degree of...

Diagnostic Procedures

In general, urinary flow rates correlate poorly with patient symptoms. Nonetheless, urinary flow assessment is frequently used as an objective parameter to follow the progress of treatment. The measurement of urinary flow may also be used in conjunction with postvoid residual assessment in identifying patients with attenuated detrusor function. Patients with moderate to severe symptoms but without diminished peak urinary flow rates (> 15 mL s) may benefit from more in-depth urodynamic...

Physical Examination

The physical examination should focus on detecting anatomic and neurologic abnormalities that contribute to the patient's symptoms. The nature of the incontinence should be determined by examining the patient with a full bladder as discussed in the following section entitled eyeball urodynamics. The neurourologic examination begins by observing the patient's gait and demeanor as he first enters the office. A slight limp or lack of coordination, an abnormal speech pattern, facial asymmetry, or...

Implantation Of Theartificial Sphincter In

Schematic representation of artificial urinary sphincter implanted in a male. (Courtesy of American Medical Systems.) size. Other options include proximal repositioning of a new cuff (80) or a double-cuff technique, which requires implanting a second cuff around the bulbar urethra (81). Cuff erosion is fortunately much less of a problem now that delayed activation is the rule (82). The most precise way to diagnose erosion is with urethroscopy. Patients may present urinary tract...

Classification Of Cystoplasty

Augmentation cystoplasty is a procedure used to increase bladder capacity by incorporating a segment of intestine or stomach into an unresected bladder. Augmentation cystoplasty is used commonly to manage intractable symptoms resulting from detrusor instability hyper-flexia or impaired detrusor compliance. Substitution cystoplasty is an operation whereby a significant amount of bladder wall is resected prior to incorporating an intestinal segment with the bladder remnant. This procedure is used...

Indications For Augmentation Cystoplasty

The major indications to perform enterocystoplasty have changed considerably since the early 1950s. Antituberculous drags have significantly decreased the end-stage manifestations of tuberculous cystitis, and, therefore, bladder reconstruction is rarely needed. In contemporary times, cystoplasty is now performed for detrusor hyperactivity resulting from such entities as poor bladder wall compliance, refractory detrusor instability or hyperreflexia, and a structurally reduced bladder capacity...

Hemispheric Dominance And Voiding Dysfunction

Hemispheric dominance has been well-established for language, whereas the temporal lobe has been linked to musical aptitude. Patients who have experienced a right hemispheric CVA have been known to incur more sexual dysfunction (38). In 1980, Khan et al. (14) postulated that patients after nondominant CVAs were less likely to have urinary incontinence. If so, what effects would a dominant hemispheric stroke have on voiding We retrospectively evaluated 44 symptomatic patients admitted to a...

Treatment of Detrusor Instability with Electrical Stimulation

Normal Urine Storage and Evacuation Disrupted Micturition Balance Mechanism of Action of Electrical Stimulation Electrical Stimulation as a Treatment Modality Conclusions References There are an estimated 13 million Americans who suffer from incontinence. Urge incontinence is conservatively estimated to account for 40 of all urinary incontinence patients (1). Of this population, two-thirds suffer from chronic or established incontinence. Yet patients diagnosed with urinary incontinence owing to...

History

Diagnosis largely depends on the history of symptoms. The elderly have been known to underreport their problems, especially when it is related to urinary incontinence. Interviewing the patient may not provide you with sufficient information on which to base a diagnosis. This is often compounded in those patients with dominant hemispheric CYAs with aphasia and those with dementia. Interviewing the caregiver (spouse, relative, or nurse's aide) may be necessary to provide additional information. A...

Urodynamics Studies

Published studies assessing a CVA's affect on the bladder have largely been performed in a retrospective fashion with evaluations occurring from days to years after their initial event. Detrusor hyper-reflexia has been demonstrated to be the main finding in their voiding dysfunction (12,14,28,30). Other studies have attempted to correlate the site of ischemic or hemorrhagic infarct with urodynamic findings but have been inconclusive (28). Burney et al. (33) performed a prospective study of 60...

Incidence Of Urinary Incontinence

The incidence of early poststroke urinary incontinence varies from 57-83 (11,26,31,32). These studies suggest that incontinence may be transitory and related to the patient's immobility and altered mental status. In a study of 151 patients, Borrie et al. (26) reported an initial incontinence rate of 60 . After 1 mo, this incidence was reduced to 29 at 1 mo. Additionally, 66 of patients with mild incontinence at 1 mo regained continence at 3 mo. Brocklehurst et al. (32) found an initial...

Treatment Overview

Although the ultimate goal of therapy is the restoration of normal voiding, this is usually not possible unless the neurologic abnormalities remit, or if the symptoms are caused by a coincidental urologic condition such as urinary tract infection or benign prostatic hypertrophy. The social and emotional consequences of urinary bladder symptoms, particularly incontinence, must always be weighed against the risks to the patients' general health imposed by the proposed therapy. For example, a...

Abnormalities Of Fillingstorage And Emptying Overview

The pathophysiology of failure of the lower urinary tract to fill with or store urine adequately may be secondary to reasons related to the bladder, the outlet, or both. Hyperactivity of the bladder during filling can be expressed as phasic involuntary contractions, as low compliance, or as a combination. Involuntary contractions are most commonly seen in association with neurologic disease or following neurologic injury however, they may also be associated with aging, inflammation or...

Etiology Of Incontinence Following Prostatectomy

When considering the etiology of urinary incontinence, it is essential to identify that leakage may occur as a result of an abnormality of bladder and or sphincteric function. Urodynamic studies provide information concerning the relative contributions of bladder and or sphincteric dysfunction in patients with incontinence after prostatectomy. The presence of isolated bladder dysfunction as the predominant cause of incontinence following prostatectomy has been identified in reports utilizing...

Extent of Bladder Resection and Preparation

The extent of bladder resection, if at all, is determined by the pathology of the underlying disease for which cystoplasty is being performed. Patients with an overactive detrusor owing to neurologic or non-neurologic disease may benefit from simple augmentation without bladder resection. In this situation the bladder is incised, either sagittally or longitudinally, and a segment of detubularized bowel is incorporated into the valved bladder. Partial or supratrigonal cystectomy is recommended...

Etiology

Urinary retention in women can arise from numerous etiologies. As was previously mentioned, the time course of onset of retention should be determined (if possible, by symptomatic appraisal). Distinguishing recent initiation of symptoms may allow the examiner to determine a transient etiology such as endocrine dysfunction, urinary tract infection, immobility, bowel dysfunction (including fecal impaction), or psychogenic cause. Any of these etiologies, alone or in combination, can produce acute...

Incidence Of Incontinence After Prostatectomy

The incidence of urinary incontinence is approximately 1-3 in patients undergoing transurethral resection of the prostate or open prostatectomy for benign disease (3,4). The incidence of incontinence following radical prostatectomy has been reported to range from 2.5 (5) to 87 (6). This wide discrepancy is a result of several factors. The definition of incontinence varies widely among series, ranging from any degree of wetting or restricted to total incontinence. In addition, the method of data...

Late Presentation

The symptoms of bladder dysfunction after established CVA include frequency, urgency, and urge incontinence (11,30). These symptoms are generally a result of detrusor hyperreflexia (14,28,29,30). Tsuchida et al. (30) evaluated 39 patients urodynamically after a CVA. The mean time from CVA to urodynamic evaluation was 19 mo (range 11 da to 13 yr). They found that 66 of the patients complained of frequency or urge incontinence and the remaining 33 had either dysuria or urinary retention. Tsuchida...

Pathophysiology Of Incontinence

Frontal cortical lesions from a CVA may affect a patient's higher cognitive functions. This may be reflected by the patient's inability to suppress a reflex detrusor contraction resulting in urinary incontinence. This incontinence can be owing to 2. CVA related language and cognitive impairments with normal bladder function or 3. Overflow incontinence secondary to detrusor hyporeflexia (mediated by either neuropathies or medications) (13). The concomitant diagnosis of dementia and benign...

Radical Perineal Prostatectomy

The perineal approach to radical prostatectomy has been described as advantageous, because the urethra is better visualized facilitating the vesicourethral anastomosis (40). Harris and Thompson (41) noted that an anatomic approach to perineal prostatectomy achieved continence rates of 97.5 after 18 mo. Several important points were stressed Fig. 3. (A-E) Steps in apical dissection of urethra. (Note Preservation of maximal urethral length by blunt mobilization of prostatic apex off urethra A...

Joseph M Khoury

Classification of Cystoplasty Indications for Augmentation Cystoplasty Contraindications to Augmentation Cystoplasty Surgical Choices in Achieving the Goals of Bladder Reconstruction Complications References Augmentation cystoplasty can provide significant relief of refractory storage symptoms such as frequency, urgency, and urge incontinence in those patients who have failed conservative measures such as pharmacotherapy, behavioral techniques, and minimally invasive procedures such as...

Subtrigonal Phenol And Alcohol Injections

Subtrigonal phenol injection has been employed in the treatment of patients with refractory detrusor instability and sensory urgency, but lack of overall efficacy and the possibility of bladder and ureteral necrosis have all but eliminated its clinical use (64,65). Most initial reports suggested that the technique was effective (66,58,64,59,65). Harris reported that 60 of patients developed an acontractile detrusor, but 30 were complicated by vesicovaginal fistula after extravesical subtrigonal...

Sling Procedures

Outlined previously, incorporation of minimally invasive techniques of bladder neck suspensions has led to contemporary modifications of sling procedures, which are now considered technically easier to perform than bladder neck suspensions. Although conceptually introduced in the early 1900s in various complex surgical forms, the contemporary reemergence of sling procedures is credited to the introduction of the rectus fascia pubovaginal sling by McGuire and Lyton in 1978 (55). Modifications of...

Electrical Stimulation As A Treatment Modality

Devices for electrical stimulation therapy are the result of observations that spontaneous or artificially evoked bladder hyperactivity can be inhibited by electrical stimulation of the pelvic floor and sacral nerves (5-7). Animal experiments and electrophysiologic studies in humans have confirmed that spinal inhibitory systems capable of interrupting a detrusor contraction can be activated by electrical stimulation (11,12). The afferent anorectal branches of the pelvic nerve, afferent...

Uroflow High Pabd Pves

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

Sns Implantation

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,...

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

Normal Void Uds

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

Uterine Mav

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...