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Common Urological Problems

Findings in Neurogenic OAB

  • - Female Urology & Urogynecology - Urodynamic Assessment of Overactive Bladder
  • Jul 09, 2010
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Tags: | bladder dysfunction | bladder overactivity | cause of incontinence | cystourethrography |

Patients with neurogenic OAB tend to have severe symptoms that are more difficult to treat pharmacologically. It is not immediately clear that the overactive contractions experienced by patients with neurological conditions are necessarily of greater amplitude or occur earlier during filling, although there is some indirect evidence to support this contention (13). Phasic detrusor contractions that crescendo and result in urge-related urine leakage appear to be more commonplace in patients with neurogenic overactivity, for example, in patients with multiple sclerosis (MS)  (Fig.  6). Voiding dysfunction, either with or without DO, also appears to be common in patients with MS. True detrusor external sphincter dyssynergia may be present in many as 40% of patients with LUTS secondary to MS (20); the incidence of bladder neck dyssynergia independent of detrusor overactivity may be even higher.

Patients with movement disorders also appear largely to suffer from DO on urodynamic testing. One unique finding among patients with movement disorders involves external sphincteric testing. Incompetent external sphincteric function resulting from denervation secondary to neuronal cell loss in the anterior horn of Onuf’s nucleus is present in the majority of patients with multiple system atrophy and can lead to debilitating urinary incontinence (21).

Both sphincteric deficiency and sphincteric bradykinesia (failure to relax) have been described in patients with PD, making surgical endeavors to treat BOO presumed secondary to prostatic obstruction treacherous because incontinence rates following transurethral prostatectomy among patients with PD have historically ranged as high as 20%. It is unclear whether this dismal rate of success will be improved with other heat-based prostatic treatments.

Patients with interruptions of the spino-bulbo-spinal pathway, typically as a result of spinal cord injury, may have debilitating urinary incontinence in addition to severely impaired bladder emptying secondary to detrusor external sphincter dyssynergia (Fig. 7).


imageFig.  6. Phasic detrusor overactivity (closed arrows)  resulting in urinary leakage (open arrows)  in patient with multiple sclerosis and urge incontinence.

Urodynamic Assessment of Overactive Bladder

Urodynamic Assessment of Overactive Bladder

In these instances, detrusor pressures may remain elevated because of the sustained detrusor contraction (particularly true in spinal cord injury) in the absence of external sphincter, and frequently bladder neck, relaxation. Concurrent fluoroscopic monitoring can be useful to evaluate for bladder wall abnormalities or vesicoureteral reflux and further evaluate sphincteric function. In patients with severe or detrusor dysfunction, bladder diverticula can develop (Fig. 8), which can ultimately result in further impairment of bladder drainage and create a haven for the development of bladder stones and malignant bladder lesions.

Conclusion
Urodynamic testing remains an integral part of the complete evaluation of patients with OAB symptoms, particularly those who fail to respond to conventional management strategies, those with specific complaints of voiding dysfunction, and those with neurogenic bladder disease.

imageFig.  7. Detrusor sphincter dyssynergia in patient with T5 spinal cord injury.  Note sustained intravesical pressure elevation (closed arrow) and simultaneous sphincteric activity (open arrow).

imageFig. 8. Video picture during voiding attempt in patient with detrusor sphincter dyssynergia. Note ballooning of proximal urethra (closed arrow) and left-sided diverticulum (open arrow).

Although the urological community continues to search for less-invasive means of monitoring bladder function, at the present time multichannel urodynamic testing is the most accurate and reliable assessment tool, and it provides a means of directing appropriate therapeutic strategies, determining treatment response, and monitoring for disease progression.

——
Gary E. Lemack, MD
——

REFERENCES

  1. Klovning A, Hunskaar S, Eriksen BC. Validity of a scored urological history in detecting detrusor instability in female urinary incontinence. Acta Obstet Gynecol Scand 1996;75:941-945.
  2. Bonde HV, Sejr T, Erdmann L, et al. Residual urine in 75-year-old men and women. A normative population study. Scand J Urol Nephrol 1996;30:89-91.
  3. van Waalwijk van Doorn ES, Meier AH, Ambergen AW, Janknegt RA. Ambulatory urodynamics: extramural testing of the lower and upper urinary tract by Holter monitoring of cystometrogram, uroflowmetry, and renal pelvic pressures. Urol Clin North Am 1996;23:345-371.
  4. Swithinbank LV, James M, Shepherd A, et al. Role of ambulatory urodynamics monitoring in clinical urological practice. Neurourol Urodyn 1999;20:249-257.
  5. Digesu GA, Khullar V, Cardozo L, Salvatore S. Overactive bladder symptoms: Do we need urodynamics? Neurourol Urodyn 2003;22:105-108.
  6. Sand PK, Hill RC, Ostergard DR. Incontinence history as a predictor of detrusor instability. Obstet Gynecol 1988;71:257-260.
  7. De Muylder X, Clae H, Neven P, De Jaegher K. Usefulness of urodynamic investigation in female incontinence. Eur J Obstet Gynecol Reprod Biol 1992;44:205-208.
  8. Colli E, Artibani W, Goka J, Parazzini F, Wein A. Are urodynamic tests useful tools for the initial conservative management of non-neurogenic urinary incontinence? A review of the literature. Eur Urol 2003;43:63-69.
  9. Lemack GE, Zimmern PE. Predictability of urodynamic findings based on the Urogenital Distress Inventory Questionnaire. Urology 1999;54:461-466.
  10. Giannitsas K, Perimenis P, Athanasopoulos A, Gyftopoulos K, Nikiforidis G, Barbalias G. Comparison of the efficacy of tolterodine and oxybutynin in different severity grades of idiopathic detrusor overactivity. Eur Urol 2004;46:776-783.
  11. Wagg A, Bayliss M, Ingham NJ, Arnold K, Malone-Lee J. Urodynamic variables cannot be used to classify the severity of detrusor instability. BJU 1998;82:499-502.
  12. Holtedahl K, Verelst M, Schiefloe A, Hunskaar S. Usefulness of urodynamic examination in female urinary incontinenceŚlessons from a population-based, randomized, controlled study of conservative treatment. Scand J Urol Nephrol 2000;34:169-174.
  13. Lemack GE, Zimmern PE, Frohman E, Hawker K, Ramnarayan P. Urodynamic distinctions between idiopathic detrusor overactivity and detrusor overactivity secondary to multiple sclerosis. Urology 2006; 67:960-964.
  14. Lemack GE, Zimmern PE. Pressure flow analysis may aid in identifying women with outflow obstruction. J Urol 2000;163:1823-1828.
  15. Nitti VW, Tu LM, Gitlin J. Diagnosing bladder outlet obstruction in women. J Urol 1999;161: 1535-1540.
  16. Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn 2000;19:553-564.
  17. Defreitas GA, Lemack GE, Zimmern PE, Roehrborn CG, Dewey RB. A urodynamic comparison of patients with Parkinson's disease and males with lower urinary tract symptoms: distinguishing neurogenic from non-neurogenic detrusor overactivity. J Urol 2003;169:1506-1509.
  18. Fitzgerald MP, Brubaker L. Urinary incontinence symptom scores and urodynamic diagnoses. Neurourol Urodyn 2003;21:30-35.
  19. Van Brummen HJ, Heintz APM, van der Vaart CH. The association between overactive bladder symptoms and objective parameters from the bladder diary and filling cystometry. Neurourol Urodyn 2004;23:38-42.
  20. Araki I, Matsui M, Ozawa K, Takeda M, Kuno S. Relationship of bladder dysfunction to lesion site in multiple sclerosis. J Urol 2003;169:1384-1387.
  21. Kirby RS, Fowler CJ, Gosling J, et al. Urethro-vesical dysfunction in progressive autonomic failure in multiple systems atrophy. J Neurol Neurosurg Psychiatry 1986;49:554-562.

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