Recent Advances in Management of the Neurogenic Voiding Dysfunction - PowerPoint PPT Presentation

1 / 53
About This Presentation
Title:

Recent Advances in Management of the Neurogenic Voiding Dysfunction

Description:

... of Detrusor function after Stroke Considerations in management of neurogenic urethral ... and sphincter spasticity Duration of effect about ... – PowerPoint PPT presentation

Number of Views:461
Avg rating:5.0/5.0
Slides: 54
Provided by: SAL27
Category:

less

Transcript and Presenter's Notes

Title: 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)
?. 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
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
Urine retention Incontinence Frequeny 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)
5
Urodynamic findings in Neurogenic
Voiding dysfunction
Detrusor areflexia Detrusor hypereflexia DHIC
?.Intracranial 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)
6
Urinary Tract Abnormalities in
Neurogenic Voiding Dysfunction
Trabeculated Bladder VUR Hydronephrosis BOO
?.Intracranial 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)
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
  • Patients 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 oclock 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
Baseline Post-RTX Stastistics
Cystometric capacity(ml) 102.131 236.688.6 Plt0.001
Bladder compliance (ml/cmH2O) 23.712.1 25.915.3 Pgt0.05
Voiding pressure (Pdet, cmH2O) 55.923.2 47.528.1 Pgt0.05
Presence of DESD (n20) 100 100
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
Baseline Post-RTX Statistics
Cystometric capacity(ml) (n41) 216106 302133 P0.000
Qmax (ml/sec) 12.77.6 21.828.9 P0.224
Voiding pressure (Pdet, cmH2O) 33.611.7 34.119.5 P0.923
Residual urine (ml) 41.152.7 49.498.9 P0.725
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 oclock 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
Baseline Post-Botox Statistics
Capacity (n53) 331.4148.8 333.2155.4 0.922
Qmax (n53) 6.7 6.7 9.4 5.7 0.003
Voiding pressure (n53) 62.0 43.1 45.937.8 0.000
MUCP (n21) 97.131.7 51.123.2 0.027
FPL (n21 3.350.59 3.300.33 0.773
PVR (n53) 225.4174.4 110.1137.6 0.000
MUCPmaximal urethral closure pressure,
FPLfunctional profile length, PVR postvoid
residual volume Comparison between baseline and
4weeks after treatment
48
Therapeutic Results after Botox Urethral
Injection for Voiding Dysfunction
Good Improved Failed
Detrusor underactivity (n27) 13 (48.2) 8 (29.6) 6 (22.2)
DESD (n18) 3 (16.7) 10 (55.6) 5 (27.8)
Dysfunctional voiding (n18) 6 (33.3) 10 (55.6) 2 (11)
Poor relaxation of urethral sphincter (n12) 3 (25) 7 (58.3) 2 (16.6)
TOTAL (n75) 25 (33.3) 35 (43.7) 15 (20)
DESDDetrusor external sphincter dyssynergia
49
Botulinum Toxin Detrusor Injection for Detrusor
Hyperreflexia
50
Btulinum A Toxin Detrusor Injection for DH
51
Initial Results of BotulinumToxin Detrusor
Injection for Incontinence
No Sex / Age Disease DESE Capacity Dysuria Incontinence
1 M / 35 DESD 250 U Improved -
2 F / 10 DI 100 U No Change -
3 F / 45 DI 200 U Improved - -
4 M / 48 DHIC 200 U Improved -
5 F / 56 DH 200 U Improved - -
52
Recovery of Detrusor function after Stroke
53
Considerations in management of neurogenic
urethral incontinence
  • Bladder compliance must be improved concomitantly
    in treatment of incontinence
  • CISC may be necessary in patients with detrusor
    areflexia
  • Balance the quality of life after surgical
    management of urethral incontinence and surgical
    complications
  • Avoid surgery with unpredictable good surgical
    outcome
Write a Comment
User Comments (0)
About PowerShow.com