Title: Recent Advances in Management of the Neurogenic Voiding Dysfunction
1Recent 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
3Neurogenic 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)
7Pseudodyssynergia in Stroke
8DESD in Multiple Sclerosis
9Detrusor external sphincter dyssynergia in
cervical SCI
10Bladder neck dysfunction and DESD in Spinal cord
lesion
11Medication 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)
12Medication 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)
13Priority 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
14Reduced frequent detrusor contractions after
Oxybutynin
15Tolterodine 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
16Side 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
17Pharmacology of Detrusor Overactivity
18Extended-release system for oxybutynin
tolterodine
19Electrostimulation 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
20Implantation of Sacral Stimulator
21Correct placement of electrode on Sacral nerves
22Surgical 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
23Surgical technique of augmentation cystoplasty
24Abdominal straining to void after
Enterocystoplasty
25Bladder Autoaugmentation
26Seromuscular enterocystoplasty
27Technique 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
28Urethral Stent Implantation
29Surgical 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
30Pubovaginal sling procedure for Urethral
incontinence
31Periurethral Teflon injection in SCI with
urethral relaxation
32Intravesical 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
33Treatment of DH Reduced Detrusor Contractility
after Capsaicin therapy
34Therapeutic 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
35Initial Response of RTX therapy
36Urodynamic Result after RTX Therapy in a SCI
patient
37Urodynamic 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
38Intravesical 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
39Urodynamic results after RTX therapy in
Neurogenic detrusor overactivity
40Therapeutic 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
41Urodynamic 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
42Botulinum 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
43Transurethral injection of Botulinum A toxin in
male urethral sphincter
44Injection of 3,6, 9, and 12 oclock Position of
Urethral Sphincter
45Reduced voiding pressure after botulinum A toxin
injection
46Reduced MUCP after Botulinum A toxin injection
47Table 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
48Therapeutic 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
49Botulinum Toxin Detrusor Injection for Detrusor
Hyperreflexia
50Btulinum A Toxin Detrusor Injection for DH
51Initial 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 - -
52Recovery of Detrusor function after Stroke
53Considerations 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