Neurourology & Urodynamics Review

H. Henry Lai MD
11/16/07
 Neuroinnervation
Pons • “Rules of 3”
• 3 “organs”
Sym • 3 “sites within LUT”
T10-L2
• 3 “nervous inputs”
• T10-L2: sympathetic,
(hypogastric n, pelvic n.)
S2-4 Para
• S2-4: parasympathetic,
(pelvic n.)
S2-4
Som • S2-4 (“Onuf’s nucleus):
somatic (pudendal n.)
• S2-S4: “sacral micturition
center”
 Storage Phase
• Bladder accommodates large
volume of urine at low pressure
(<12 cm) without involuntary
Sym contractions
T10-L2
(-) • >40 cm puts upper tracts at risk
• Normal sensation
• Outlet tight, even with valsalva
Para • T10-L2: sympathetic relaxes
S2-4 bladder, keep BN tight
(+)
S2-4 • S2-4: parasympathetic quiet
(+) • S2-4 (“Onuf’s nucleus):
Som
pudendal, keep ES tight.
• ES tighter as the bladder fills
(“guarding reflex”)
 Emptying Phase
• Bladder contractions to
completion without interruption
Sym • Outlet opens
T10-L2
• T10-L2: sympathetic quiet
• S2-4: parasympathetic active,
releases acetylcholine  M3
Para muscarinic receptors
S2-4
• S2-4 (“Onuf’s nucleus)
(+) pudendal, quiet
S2-4
Som
 S2-4 sacral micturition center is negatively
controlled by the pontine micturition center
Pons
• Storage phase
• Conscious control
Sym • Pontine micturition center shuts
T10-L2
down the S2-4 sacral
(-) micturition center
(-)
S2-4 Para
(+)
S2-4 (+)
Som
 S2-4 sacral micturition center is no longer
inhibited by the pontine micturition center
Pons • Emptying phase
• Conscious voiding
Sym
T10-L2

S2-4 Para
(+)
S2-4
Som
 Spinal shock (acute SCI)

Pons • Spinal shock (first 3 months)

• Flaccid bladder
Sym • Urinary retention
T10-L2
• Flaccid lower extremities

S2-4 Para

S2-4
Som
 Chronic suprasacral SCI (above spinal S2)

Pons • After spinal shock is recovered

• Bladder behavior?
Sym • External sphincter behavior?
T10-L2

S2-4 Para

S2-4 (+)
Som
 Chronic suprasacral SCI (above spinal S2)

Pons • No pontine inhibition on the sacral

micturition center
• Bladder behavior?
Sym  Detrusor hyperreflexia
T10-L2  Neurogenic detrusor overactivity
 Poor detrusor compliance
• External sphincter behavior?
 In some but not all patients, DESD
S2-4 Para (detrusor external sphincter
dyssynergia)

S2-4 (+)
Som
 Neurogenic detrusor overactivity

QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.

Early first sensation if <75 cc, Reduced capacity <250 cc

 Poor bladder compliance

Loss of bladder P(ves)

elasticity.
P(abd)
Why is poor QuickTime™ and a
detrusor TIFF (LZW) decompressor
are needed to see this picture. P(det)=P(ves)
compliance
minus P(abd)
an issue?

What is
DLPP?
 Detrusor leak point pressure (DLPP)

Leaks
P(det)

DLPP

Poor compliance

Normal

Volume
 Detrusor leak point pressure (DLPP)

Leaks
P(det)

DLPP > 40

40 cm
“Danger zone”

Poor compliance Volume

 Detrusor leak point pressure (DLPP)

P(det)

Leaks
40 cm
“Safe”
DLPP < 40

Improved bladder compliance Volume

 Chronic suprasacral SCI (above spinal S2)

Pons • No pontine inhibition on the sacral

micturition center
• Bladder behavior?
Sym  Detrusor hyperreflexia
T10-12  Neurogenic detrusor overactivity
 Poor detrusor compliance
• External sphincter behavior?
 In some but not all patients, DESD
S2-4 Para (detrusor external sphincter
dyssynergia)

S2-4 (+)
Som
 DESD

QuickTime™ and a
P(det) TIFF (LZW) decompressor
are needed to see this picture.

P(ure)

EMG

Loss of compliance DESD

 Chronic suprasacral SCI (above spinal T6)

Pons • No pontine inhibition on the sacral

micturition center
• Bladder behavior?
Sym  Detrusor hyperreflexia
T10-12  Neurogenic detrusor overactivity
 Poor detrusor compliance
• External sphincter behavior?
 In some but not all patients, DESD
(detrusor external sphincter

S2-4 Para dyssynergia)

• What additional condition will you be

S2-4 (+) concerned about?
Som
 Autonomic dysreflexia
• Complete SCI at T6 or above
• Sympathetic “outpour” in response to noxious
stimuli (bladder distention, constipation)
• Hypertension, headache, bradycardia, flushing
and sweating, bradycardia, seizure, cerebral
hemorrhage, death
• What do you do?
• How to prevent it?
 Prophylatic procardia SL, proscar
 Chronic suprasacral SCI (above spinal T10)

Pons • No pontine inhibition on the sacral

micturition center
• Bladder behavior?
Sym  Detrusor hyperreflexia
T10-12  Neurogenic detrusor overactivity
 Poor detrusor compliance
• External sphincter behavior?
 In some but not all patients, DESD
(detrusor external sphincter

S2-4 Para dyssynergia)

(+) • Above T6: autonomic dysreflexia

S2-4 (+)
Som • Above T10: detrusor internal sphincter
dyssynergia (Tx: alpha blockers,
incision of bladder neck)
 S2-4 SCI, peripheral nerves

Pons • Spinal level S2-4 corresponds to bone

level L5-S1
• Cauda Equina starts at bone level L2
Sym
T10-L2 • Bladder underactivity (areflexia)
• Fixed resistance or flaccid outlet
• No DESD

S2-4 Para • Diabetic autonomic neuropathy

• Lumbar spine disc herniation
S2-4 • Radical surgery (radical hysterectomy,
APR, pelvic fracture)
Som • Spina Bifida
• Spina Bifida Occulta
• Cauda Equina syndrome
• Tethered Cord
 A brief summary

• (1) What is the BLADDER doing?

• (2) What is the SPHINCTER doing?
• (3) Is there DYSSYNERGIA between bladder and sphincter?

• Suprapontine (e.g. CVA)?

• Suprasacral (above S2)?
• Suprasacral (above T10)?
• Suprasacral (T6 or above)?
• Sacral lesion (herniated L5 lumbar disc)?
• Peripheral lesion?
 Classification of Voiding Dysfunction

• Failure to empty (retention)

 BLADDER problem?
 OUTLET problem?

• Failure to store (incontinence)

 BLADDER problem?
 OUTLET problem?
 Failure to Empty
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)
• Neurogenic
• Myogenic
• OUTLET problem
 Anatomic obstruction
• BPH
• Stricture, bladder neck contracture
 Functional obstruction
• DESD
• DISD
• Psychogenic
 Failure to Store

• BLADDER problem:
 Detrusor overactivity
• Involuntary contractions
• Sensory urgency
 Poor bladder compliance
• OUTLET problem:
 Intrinsic sphincteric deficiency
 Nonfunctional bladder neck
 Failure to Empty
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)

 What are the options?

 Failure to Empty Tx
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)

 Celan Intermittent catheterization (CIC)

• Hand function (excludes quad)
• Cognitive function
• Motivation, follow instructions
• Goal keep cath volume <400 cc, cath before 12 cm water
• Add anticholinergics if leaks between cath
• Not for urethral strictures, autonomic dysreflexia
• Recurrent infection: sterile technique, hydrophilic-coated cath
 Failure to Empty Tx
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)

 Foley, SPT
• Compared to CIC, higher risks of pyelo, cystitis, renal stones,
bladder stones, poor bladder compliance
• Foley: higher risks of prostatitis, epididymitis, periurethral abscess,
Fournier’s gangrene, fistula, traumatic hypospadia, eroded “lead-
pipe” female urethra, worse sexual function
• Must have surveillance cysto every yr after 8-10 yrs
• 25 times higher risk than general, 5 times higher than CIC
• Squamous cell carcinoma, transitional cell carcinoma
• Cytology not useful for SCC, lack of sensitivity (71%) for TCC
• Overall prognosis is poor, many already have advanced disease
 Failure to Empty Tx
• BLADDER problem
 Detrusor underactivity
(areflexia, hypocontractility)

 Ileovesicostomy (the “chimney

operation”) - no hand function
but does not want foley or SPT QuickTime™ and a
or cannot tolerate (e.g. TIFF (LZW) decompressor
are needed to see this picture.
autonomic dysreflexia) and
don’t mind having an
abdominal stoma bag

 Advantage: like a SPT but

without foreign body, uses
ileum as the “SPT” instead
 Failure to Empty Tx
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)

 Crede or Valsalva
• Only with minimal outlet resistance
• Non-physiologic, no synergy, never quite empty
• Contraindicated in reflux, hydronephrosis

 Bethanechol
• Cholinergic agonist
• Never been shown in randomized trial to work

 Neuromodulation
• Experimental: 3 of 12 have 505 improvement in symptoms and signs
 Failure to Empty Tx
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)
 Neurogenic
 Myogenic
• OUTLET problem
 Anatomic obstruction
• BPH
• Stricture, bladder neck contracture
 Functional obstruction
• DESD
• DISD
• Psychogenic
 Failure to Empty Tx
• OUTLET problem
 DESD
 Two approaches:
• Don’t mess with the outlet, keep the patient dry, and empties bladder
with CIC, SPT, foley, ileovesicostomy. Should not do crede or
valsalva (since high outlet resistance).

• Ablate the functional outlet resistance, let urine drips continuously

into a condom catheter
• Problems with condom catheter:
 Infection risks of indwelling catheter
 Difficult to fit
 Skin breakdown
 Only for males
 Malleable penile prosthesis (erosion at the tip of penis, insensate)
 Failure to Empty Tx
• OUTLET problem
 DESD - ablate the functional outlet obstruction

 Transurethral sphincterotomy
• Problems: hemorrhage, transfusion (5-26%), clot retention,
“irreversible”, ED, stricture, high failure rates (15-50%)
• Failure if DLPP > 40 cm, upper tract damage, repeat
• Laser > electrocautery

 Urolume (permanent urethral stent)

• Encrustation, migration, pain, non-epithelize, stenosis, stent
removal (15%) = VERY DIFFICULT, repeat stenting (27%)
 Failure to Empty Tx
• OUTLET problem
 DESD - ablate the functional outlet obstruction

 Balloon dilation
• Bleeding, failure

 Botulinum Toxin
• Off label use (no GU approved uses)
• Used to treat DESD, or poor detrusor compliance
• Average action 3-4 months, reinject every 6-9 months or so
 Botulinum Toxin

QuickTime™ and a QuickTime™ and a

TIFF (LZW) decompressor TIFF (LZW) decompressor
are needed to see this picture. are needed to see this picture.

Cleavage of SNARE (SNAP25), vesicals cannot dock and

acetylcholine cannot be released, chemical denervation
 Failure to Empty Tx
• BLADDER problem
 Detrusor underactivity (areflexia, hypocontractility)
 Neurogenic
 Myogenic
• OUTLET problem
 Anatomic obstruction
• BPH
• Stricture, bladder neck contracture
 Functional obstruction
 DESD
• DISD (alpha blockers, bladder neck incision)
• Psychogenic (pelvic floor retraining, biofeedback)
 Failure to Empty Tx
• OUTLET problem
 DESD - ablate the functional outlet obstruction

 Balloon dilation
• Bleeding, failure

 Botulinum Toxin
• Off label use (no GU approved uses)
• Used to treat DESD, or poor detrusor compliance
• Average action 3-4 months, reinject every 6-9 months or so
 Failure to Store Tx

• BLADDER problem:
 Detrusor overactivity
 Poor bladder compliance

• OUTLET problem:
 Intrinsic sphincteric deficiency
 Nonfunctional bladder neck
 Failure to Store Tx

• BLADDER problem:
 Detrusor overactivity, Poor bladder
compliance

 What are the options?

 Failure to Store Tx
• BLADDER problem:
 Detrusor overactivity, Poor bladder compliance

 Anticholinergics
• Reduce intravesical pressure, reduce DLPP, reduce
uninhibited contractions, increase bladder capacity,
keep pt dry between CIC, increase cath intervals
• Dry mouth, constipation (neurogenic bowel)
• Intravesical therapy
 Failure to Store Tx
• BLADDER problem:
 Detrusor overactivity, Poor bladder compliance

 Vanilloid Receptor Agonist

• Intravesical capsaicin = intolerable side effects
• Intravesical resiniferatoxin (RTX) = 62% efficacy, repeat
injections q9m, not reproducible
 Botulinum Toxin
• Off-label use (not FDA-approved)
• 300U vs 200U, spare trigone or not, intramuscular vs
submocosal, reinjection q9m, not paid by insurance
 Neuromodulation: 56% response, better than retention
 Failure to Store Tx
• BLADDER problem:
 Detrusor overactivity, Poor bladder
compliance

 Augmentation:
• Metabolic complications if use ileum, large bowel?
 K, Cl, acidosis or alkalosis
• What if you use jejunum?
• What if you use stomach?
• What vitamin deficiency can you get?
 Failure to Store Tx
• BLADDER problem:
 Detrusor overactivity, Poor bladder compliance

 Augmentation:
• Metabolic complications if use ileum, large bowel?
 Low K, high Cl, non-anion metabolic acidosis
• What if you use jejunum?
 High K, low Cl, non-anion metabolic acidosis
• What if you use stomach?
 Low K, low Cl, metabolic alkalosis
• What vitamin deficiency can you get? B12
 Failure to Store Tx
• BLADDER problem:
 Detrusor overactivity, Poor bladder compliance

 Augmentation:
• Recurrent UTI
• Persistent mucus
• Stone formation
 35% for large bowel segment, 13% for small bowel segment
• Incomplete emptying
 CIC needed in 15-20% of pts treated for NDO
 Patient must be ready for this possibility
• Tumor risk: overall very low, Ileum, colon > stomach
 ? Greater inflammation, ? Higher oxygen radicals
 Failure to Store Tx

• BLADDER problem:
Detrusor overactivity
Poor bladder compliance

• OUTLET problem:
 Intrinsic sphincteric deficiency
 Nonfunctional bladder neck
 Failure to Store Tx
• OUTLET problem: ISD, nonfunctional BN
 What are the options?
 Failure to Store Tx
• OUTLET problem: ISD, nonfunctional BN
 Alpha-agonist (sudafed) - mild cases only
 Kegal exercise - mild cases only
 Bulking agents:
• Poor durability overtime, needs multiple injections
• Less invasive
• Collagen: requires skin testing
• Useful to bulk up incompetent ileocecal valve in Indiana
augmentation with catheterizable stoma, or Indiana pouch
 Failure to Store Tx
• OUTLET problem: ISD, nonfunctional BN
 Sling procedures
• Rectus fascial sling placed at the bladder neck, combined approach
better than transvaginal approach, 78-100% continence
• HIGH tension, (not tension free), OBSTRUCT the urethra
• SIS and other biologics, durability?
• Synthetic Gore-Tex at bladder neck is a disaster (83% erosion)
• Mid-urethral sling acceptable for female SCI
 AUS
 Bladder neck closure
 Urinary diversion (ileal conduit, Indiana pouch), pyocystitis risk
 Cystectomy + diversion (cancer, intractable fistula)
 If you close the bladder neck …

• Continent Catheterizable Stoma

 Cannot cath per urethra (stricture, obesity, leg spasticity),
or requires bladder neck closure
 Moves the catheterizable channel from the urethra to
abdomen
 Cath through the abdominal stoma instead of through the
urethral meatus
 Channel
• Tapered small bowel (Monti)
• Tapered small bowel + ileocecal value (continent mechanism) +
ascending colon patch onto the bladder (augment patch) (Indiana)
• Appendix (Mitrofanoff)
 Classification of Voiding Dysfunction

• Failure to empty (retention)

BLADDER problem? Detrusor underactivity
OUTLET problem? DESD, DISD

• Failure to store (incontinence)

BLADDER problem? NDO, poor compliance
OUTLET problem? ISD, nonfunctioning BN
Good Luck!