Urinary disturbances following

traumatic brain injury: Clinical

and urodynamic evaluation

Aditya Pramanta
Urology

Introduction
Literature regarding problems related to urinary dysfunction following TBI is scarce
Urinary disturbances are associated with poor overall
functional outcome following TBI and stroke,
regardless of the injury locale
To characterize the urinary disturbances (symptomatic
and asymptomatic) in patients following TBI
To correlate urinary disturbances with the nature and
severity of the TBI and identify predictors of urinary
disturbances

Material And Methods

A prospective cross-sectional study
Patients surviving acute moderate and severe TBI
(GCS of 13 or below at admission) at 312 months
post-injury seen at follow-up in the neurosurgery/
post-trauma clinic/ neurorehabilitation outpatient
department was completed.
34 subjects were recruited. The Glasgow Coma
Scale (GCS) at the time of the acute TBI was
recorded and severity of TBI was graded into
moderate (GCS 913) and severe (GCS 38)

 Initial cranial imaging findings were classified as focal (predominant

involvement of a single lobe/region), multifocal (multiple significant
unilateral or bilateral lesions) or diffuse injury (diffuse axonal injury,
cerebral edema or traumatic subarachnoid bleed)
Persistent deficits (cognitive, communication, motor, and behavioral)
were documented during the interview. Cognition was assessed with
a locally validated version of Mini Mental State Evaluation (MMSE)
Presence of clinically symptomatic urinary disturbances (as reported
by the patient or his caretakers) at the time of inclusion in the sample
was recorded.
All patients were subjected to an incontinence questionnaire and the
International Prostate Symptoms Score (IPSS) questionnaire. The
functional status of the patients at the time of study was evaluated
with Glasgow Outcome Scale (GOS)

Techniqueofurodynamicstudy
Multi-channel cystometric evaluation was car ried out in all
patients using a commercially available device (Phoenix MK2, Albyn Medical, UK; Version 1.81).
Urodynamic assessment was carried out in accordance with
the guidelines laid down by the International Continence
Society
Filling cystometry was performed in the supine position.
Normal saline at 37C was used as an infusion at rates
between 10 and 20 ml/min. A 6-F double-lumen catheter was
employed for infusion and recording of intravesical pressures
(a fluid coupled transducer was used), with the abdominal
pressure being recorded with a per-rectal infant feeding tube

 Infusion was terminated after a volume of

500ml.
Residual urine was measured by introducing
a catheter after the patient had voided
voluntarily. The parameters identified for
the purpose of this study were maximum
cystometric capacity (Cmax), bladder
compliance, detrussor over activity and post
voidal residual urine (PVR)

 The Cmax was defined as the volume at which

the patient feels he/she could no longer delay
micturition. The absolute values of Cmax were
recorded in ml.
Compliance was the relation between change in
bladder volume and change in detrussor pressure
Detrussor over activity was an urodynamic observation characterized by involuntary detrussor
contrac- tions during filling phase which may be
spontaneous or provoked

 PVR was the volume of urine left in the

bladder at the end of micturition
PVR was considered significant when it was
more than 20% of the total volume, or when
the absolute volume was equal to or more
than 50 ml.

Results

Discussion
The aim of the present study was to detect lower urinary tract dysfunction among subjects with moderate
and severe TBI
Following TBI, micturition disturbances have not been a
topic of focused research. Few studies have attempted
to document such abnor-malities
The types of abnormalities detected were overactive
detrussor and poor detrussor compliance.
The predominant abnormality in this study group was
de trussor over activity (n = 8). This is commonly found
in lesions affecting the brain above the pons

 In the present study, frontal lobe injuries

were found in 7 of 11 subjects with
abnormal urodynamic studies
No relation between presence of cognitive
and behavioral problems and urodynamic
abnormalities was found.
The bladder dysfunction in the present
study may be due to direct injury to brain
circuits involved in control of micturition.