Urodynamic Responses to Anal Stretch in Patients With Detrusor Sphincter Dyssynergia

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1 1748 ORIGINAL ARTICLE Urodynamic Responses to Anal Stretch in Patients With Detrusor Sphincter Dyssynergia Yu-Hui Huang, MD, Sung-Lang Chen, MD, Su-Ju Tsai, MD, Liu-Ing Bih, MD, Henry L. Lew, MD, PhD 1,2 outlet obstruction in patients with SCI. It causes impaired micturition and high intravesical pressure that leads to potentially life-threatening urologic complications such as recurrent urinary tract infections, vesicoureteral reflux, and hydronephro- ABSTRACT. Huang Y-H, Chen S-L, Tsai S-J, Bih L-I, Lewsis. 1,3 If left untreated, it could result in progressive damage to HL. Urodynamic responses to anal stretch in patients withthe kidneys. detrusor sphincter dyssyngergia. Arch Phys Med Rehabil 2008; Based on the observation that some paraplegic patients may 89: void a substantial volume of urine during the performance of 4 digital bowel programs, Kiviat et al proposed an anal stretch Objective: To evaluate the urodynamic responses to anal technique to assist voiding in paraplegic patients. In their stretch in patients with detrusor sphincter dyssynergia (DSD). report, this technique reduced the external sphincter hypertonicity, but the patients needed simultaneous Valsalva maneuver Design: Descriptive study. Setting Rehabilitation hospital affiliated with a medical or the assistance of a lumbosacral corset to produce adequate university. intra-abdominal pressure for voiding. Simultaneous relaxation Participants: Patients (N 36) with suprasacral spinal cord of the detrusor and anal sphincter muscles by anal stretch injury who had DSD confirmed on cystometrography was reported in other reports. However, Sundin et al Interventions: Not applicable. reported, in a study with cats as subjects, that anal stretch Main Outcome Measures: Detrusor pressure, urethral pressure, and summated electromyogram of external urethral did not change bladder contraction under low intravesical pressure ( 10mmHg). Instead, it reduced bladder contraction sphincter on cystometrography. under high intravesical pressure (15 25mmHg). Rodriquez and Results: The urodynamic responses to anal stretch were Awad 9 found that although vigorous anal stretch inhibited evaluated in the first half (time 1, 1 15s) and the second half bladder contraction, mild stretch increased the intravesical (time 2, 16 30s) of the evaluation time period. The activity pressure of in 5 of 12 SCI patients. In a more recent study of 7 external urethral sphincter was reduced significantly in both paraplegic patients, Shafik 10 reported that detrusor contraction times 1and 2(P 0.5). The medians of reduction percentages were 33% and 35% for times 1 and 2, respectively. The was facilitated by rapid anal distension but not by gradual distension. change of detrusor pressure was not significant in either time Despite these controversies, most researchers suggested that 1or time 2. anal stretch could be a useful technique to facilitate voiding Conclusions: Anal stretch can reduce the activity of external in paraplegic patients, except for those with anal fissures or urethral sphincter without significant change in detrusor intractable hemorrhoids. 5 However, previous studies either pressure. lacked measurable data or had very small sample sizes. An Key Words: Anus; Neurogenic bladder; Rehabilitation; objective means to evaluate the effect of anal stretch is needed Urethra; Urodynamics. before one could reasonably recommend its clinical use by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ETRUSOR SPHINCTER DYSSYNERGIA, defined as an D involuntary contraction of the external urethral sphincter during detrusor contraction, is a common cause of bladder From the Department of Physical Medicine & Rehabilitation (Huang, Tsai, Bih) and Institute of Medicine (Huang), Chung Shan Medical University, Taichung City, Taiwan; Departments of Physical Medicine & Rehabilitation (Huang) and Urology (Chen), Chung Shan Medical University Hospital, Taichung City, Taiwan; and Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine and PM&R Service, VA Palo Alto Health Care System, Stanford, CA (Lew). Supported by the National Science Council of the Republic of China (grant no. NSC B040006). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Su-Ju Tsai, MD, Dept of Physical Medicine & Rehabilitation, Chung Shan Medical University, 1142 Section 3, Tay-Yuan Rd, Taichung City, 406, Taiwan, sujutsai@ms71.hinet.net /08/ $34.00/0 doi: /j.apmr In this study, we evaluated 36 patients with suprasacral SCI who exhibited findings of DSD. Videourodynamic examination, including triple-lumen cystometry (ie, urethrocystometry) and summated electromyogram, was used for the evaluation and quantification of detrusor and external urethral sphincter responses to anal stretch. Our intention was to reassess this technique, which has been proposed in the past but has not remained in general clinical use. METHODS Participants All subjects were recruited from a rehabilitation hospital affiliated with a major medical school. The inclusion criteria were (1) patients with suprasacral SCI who were medically stable at the time of screening and recruitment and (2) the presence of hypertonicity of external urethral sphincter with or without detrusor contraction on videourodynamics. Hyperto- AIS ASIA CIC DSD SCI List of Abbreviations ASIA Impairment Scale American Spinal Injury Association clean intermittent catheterization detrusor sphincter dyssynergia spinal cord injury

URODYNAMIC RESPONSES TO ANAL STRETCH IN DSD, Huang 1749 Table 1: The Basic Demographic Data of 36 Patients With Suprasacral SCI Characteristics Values Age (y) 46 15.6 Injury duration (d) 13.1 19.

2 URODYNAMIC RESPONSES TO ANAL STRETCH IN DSD, Huang 1749 Table 1: The Basic Demographic Data of 36 Patients With Suprasacral SCI Characteristics Values Age (y) Injury duration (d) Sex Male 29 (80.6) Female 7 (19.4) Injury level Cervical 27 (75) Thoracic 7 (19.4) Lumbar 2 (5.6) AIS grade A 13 (36.1) B 10 (27.8) C 6 (16.7) D 7 (19.4) NOTE. Values are mean SD or n (%). nicity of external urethral sphincter was defined as markedly increased sphincter activity on electromyography with increasing bladder volume or poor relaxation of external sphincter at detrusor contraction. The exclusion criteria were (1) marked anal-rectal hemorrhoid on physical examination, (2) autonomic dysreflexia while undergoing urodynamic examination, (3) previous treatment of external urethral sphincter hypertonicity (including neurolysis, botulinum toxin injection, and sphincterotomy), and (4) infection of the perianal area. The ethics committee of Chung Shan Medical University Hospital approved the study program, and informed consent was obtained from each subject. A total of 36 patients were enrolled from August 2004 to July All of these patients had neurogenic bladder dysfunction, the upper motoneuron type, with hypertonicity of external urethral sphincter on urodynamic examinations. Injury levels were defined according to the ASIA classification system of SCI. Our patients had injury levels at the cervical, thoracic, or lumbar cord. All were suprasacral and resulted in DSD. Subjects were further divided according to the AIS into grades A, B, C, and D for further analysis. Basic demographic data of these patients are shown in table 1. Procedures Videourodynamic examinations performed with a Dantec Urodyn 5500 apparatus a included urethrocystometry and transperineal electromyogram. Urethrocystometry was performed by a triple-lumen catheter that could measure intravesical pressure and urethral pressure synchronously. The measuring point of urethral pressure is at the level of the maximal urethral pressure. 11 Transperineal electromyography of the external urethral sphincter was obtained through disposable concentric needle electrodes. The needle electrode placement in women is just lateral to the urethral meatus to a depth of 15mm. In male patients, the needle is inserted into the perineum at the midline about 1.5 to 2cm anterior to the anus. A gloved finger in the rectum monitors the position of the prostate while the electrode is being directed toward its apex. The final localization is made by monitoring motor unit activity electromyographically and by examining the needle position fluoroscopically. 12 The following parameters were recorded before, during, and after anal stretch: (1) detrusor pressure, (2) urethral pressure, and (3) summated electromyographic activity of external urethral sphincter. Urine leakage during anal stretch was also recorded. Anal stretch was performed with an anal dilator (fig 1). This apparatus has 2 leaves attached to a holder. The width and length of the leaf were 1.5 and 5cm, respectively, which were similar to the width and length of adult human fingers. Baseline data were collected while the dilator was initially inserted and left in place (without opening) for 30 seconds. Then, it was opened to a 5-cm width for another 30 seconds while postdilatation measurements were recorded. Data Analysis All data collected during anal stretch were divided into the first half (time 1, 1 15s) and the second half (time 2, 16 30s) of the 30-second duration. The average detrusor pressure, urethral pressure, and summated electromyographic activity during 3 specific intervals (baseline, time 1, time 2) were used for analysis. The percentages of change in these 3 parameters were calculated as: (baseline value time 1 or time 2 value)/baseline value. All statistic analysis was performed by SPSS software. b Because the analysis of the Kolmogorov-Smirnov normality test revealed that our data were not normally distributed (we have some extreme values and small sample size), all analysis was done by the nonparametric method. We used the Friedman analysis of variance and post-hoc analysis by Wilcoxon signedrank test to compare the difference of urodynamic parameters between these intervals. A Wilcoxon signed-rank test was also used to analyze the difference of summated electromyographic activity before and after anal stretching (time 1) within subgroups of the AIS. We used the Kruskal-Wallis method to compare the difference in summated electromyographic activity change percentage (of time 1) between patients with different SCI levels (per ASIA classifications). Wilcoxon rank-sum tests were used for post hoc comparisons and also to compare the differences between sex and duration after SCI ( 6mo or 6mo). The level of significance was set at P less than.05. Fig 1. (A) The leaf size and (B) the opening width of the anal dilator (right) were similar to those of human fingers (left).

3 1750 URODYNAMIC RESPONSES TO ANAL STRETCH IN DSD, Huang Table 2: The Baseline Values and Values After Anal Stretch in 3 Parameters of Urodynamic Examination Parameters Median Range Summated electromyographic activity Baseline Time Time Urethral pressure Baseline Time Time Detrusor pressure Baseline Time Time RESULTS The percentage changes of the 3 designated urodynamic parameters (detrusor pressure, urethral pressure, summated electromyographic activity) are shown in table 2 and figure 2. The summated electromyographic activity markedly declined after anal stretch both in times 1 and 2 (medians of change percentages were 33% and 35%, respectively) (P.001). The urethral pressure also decreased slightly with the medians of change percentages for times 1 and 2 being 8% and 9%, respectively, but statistical significance was seen only in time 2 (P.05). The detrusor pressure values were slightly increased in time 1 (median of change, 9%) and then returned to baseline in time 2 (median of change, 1%), but these changes were not statistically significant. On the average, the maximal reduction of summated electromyographic activity occurred at seconds after the initiation of anal stretch. Figure 3 shows a typical urodynamic representation of one of these patients. As Fig 3. Urodynamic graphs of one of the SCI patients. The initial fluctuation of these 3 parameters was induced by placement of anal dilator (point X). We waited for 30 seconds until these parameters stabilized, and the values of the last 15 seconds were collected for baseline value (b). Then, the anus was stretched for an additional 30 seconds (from point Y to point Z). This duration of stretching was further divided into first half (t1) and second half (t2). Abbreviations: semg, summated electromyography; PDet, detrusor pressure; PUre, urethral pressure. one can see, from Y to Z, the electromyographic activity of the external urethral sphincter decreased without a significant change of urethral pressure. Also, on this segment of curve, the detrusor pressure increased initially and then decreased to baseline value. The analysis of summated electromyographic activity changes during time 1 in the AIS subgroups is shown in table 3 and figure 4. The external urethral sphincter summated electromyographic activity was significantly reduced in AIS grade A and B groups (P.05) but not in AIS grade C and D groups. The difference of summated electromyographic activity changes between groups with different sex, duration after injury, and injury levels were not statistically significant. Among the 36 patients evaluated, 23 patients (63.9%) who had either stopped leakage or no leakage before anal stretch had urine outflow during anal stretch. The only complication of this procedure noted in 3 patients (8.4%) was minimal anal bleeding. DISCUSSION Relaxation of the external urethral sphincter after anal stretch was reported by several researchers in the past, 4-7 but no Table 3: The Baseline Values and Values After Anal Stretch (Time 1) of Electromyographic Activity in Patients With Different AIS Grades Fig 2. The change percentages of 3 video-urodynamic (VUD) parameters. The medians were (1) summated electromyographic activity (semg): 33% decrement for time 1 (t1) and 35% decrement for time 2 (t2); (2) urethral pressure (PUre): 8% decrement for time 1 and 9% decrement for time 2; and (3) detrusor pressure (PDet): 9% increment for time 1 and 1% decrement for time 2. *Significant change versus baseline value. Grade Baseline After Stretch A 4.3 ( ) 1.8 ( ) B 4.8 (1.3 18) 2.6 ( ) C 6.5 ( ) 7.4 ( ) D 3.8 ( ) 3.7 ( ) NOTE. Values are median (range).

4 URODYNAMIC RESPONSES TO ANAL STRETCH IN DSD, Huang 1751 Fig 4. The change in percentages of summated electromyographic (semg) activity (during time 1) in patients for different AIS grades. The medians of change percentages were 52.4%, 40.5%, 0.3%, and 4% decrement in groups with AIS grades A, B, C, and D, respectively. *Significant change versus baseline (P<.05). quantitative data from urodynamic studies were available for analysis. Our results showed that anal stretch for 15 or 30 seconds could reduce the summated electromyographic activity of external urethral sphincters by 33%. On the average, the maximal relaxation effect occurred at 6.6 seconds after the initiation of anal distension. Because we stratified these patients into subgroups of AIS grades A, B, C, and D, the overall picture of the relaxation effect was clearer. In AIS grades A and B, electromyographic activity significantly decreased after anal stretch, but in AIS grades C and D there was no difference. This may suggest that the more complete the SCI, the better the effect of external urethral sphincter relaxation by anal stretch. It is also possible that painful sensation from anal distention could be perceived in patients with preserved sensation around the perianal area. If patients had residual innervation of the pelvic floor muscles (AIS grades C and D), anal distention could result in increased contraction of these muscles. The urethral pressure responses to anal stretch were less prominent and more delayed than the electromyographic activity change in our observation. We saw a medium change of 11% at the second period of anal distension. The urethral pressure may be determined by the activity of the urethra sphincter and many other factors causing outlet obstruction, such as benign prostate hypertrophy and urethral stricture. Our patient group had a mean age of years, and, according to 1 report, 50% of the male population has pathologic benign prostate hyperplasia when they are 51 to 60 years old. 13 Urethral stricture was not an uncommon complication after SCI. It occurred in 5% of all patients who had ever performed CIC at any time after injury and in 19% of those who had performed CIC for over 5 years. 14 The effect of these factors on urethral pressure was hard to evaluate because we had a small sample size of 36 patients. It s not possible to stratify these patients according to AIS and then analyze these factors within each subgroup. However, urethral pressure measurement is inherently unstable. Variations in the measured pressure, up to 50% of the measured value, could be seen at different orientations of the catheter. 15 The static urethral pressure profile also had time variations that would decrease the reproducibility and comparability of this measurement. 16 Detrusor activity was inhibited by anal stretch according to the observations of Donovan, 5 Low, 6 O Shaughnessy, 7 and colleagues. Rodriquez and Awad 9 reported that mild stretch to the anus could be facilitative (5/12 patients), but vigorous stretch caused inhibition (7/12 patients). Shafik 10 found that rapid anal inflation, either in normative volunteers or paraplegic patients, increased the intravesical pressure, but slow anal distension did not. The underlying mechanism was explored by his findings that this response could be blocked by paralysis of the internal anal sphincter but not the external anal sphincter. This reflex relationship between the internal anal sphincter and the urinary bladder was named anovesical reflex. 10 In our experiment, we applied a vigorous and rapid stretch to the anal sphincter with a 5-cm depth, which reached the level of internal anal sphincter. 17 However, the response of detrusor pressure was not significant with only a minimal increment in the first half (median of change, 9%). While performing anal stretch, we also observed that 23 patients (63.9%) who had either stopped leakage or no leakage before anal stretch had urine outflow during anal stretch. In our clinical experiences, some suprasacral SCI patients could use the anal stretch technique, without the assistance of abdominal strain, to void efficiently. These were compatible with the results of urodynamic examinations that anal stretch could relax the external sphincter without inhibition of detrusor contraction. In our report of 36 cases, the complication of anal stretch is minimal (eg, transient anal bleeding after stretch, which was noted in 3 patients [8.4%]). However, this study was performed on a single occasion in 36 patients by using a device, rather than digital manipulation. It is not clear if further trauma would occur with the ongoing use of this technique. Study Limitations In this study, we presented the urodynamic responses to anal stretch. The limitation of our study is that we did not include the results of postvoid residuals and the acceptability of anal stretch. We performed anal stretch for only 30 seconds with little urine leakage. In addition, postvoid residuals with and without anal stretch were not evaluated. Thus, future studies are needed to assess whether this technique is clinically useful and whether it maintains acceptability over a longer period. CONCLUSIONS Our study revealed that anal stretch for 30 seconds could significantly reduce the activity of the external urethral sphincter without a change in detrusor pressure. The complication rate is low. If performed properly, anal stretch could potentially be an effective way to assist voiding in suprasacral SCI patients with DSD. References 1. Blaivas JG, Barbalias GA. Detrusor-external sphincter dyssynergia in men with multiple sclerosis: an ominous urologic condition. J Urol 1984;131: Blaivas JG, Sinha HP, Zayed AA, Labib KB. Detrusor-external sphincter dyssynergia. J Urol 1981;125: Thomas DG. Spinal cord injury. New York: Churchill Livingstone; Kiviat MD, Zimmermann TA, Donovan WH. Sphincter stretch: a new technique resulting in continence and complete voiding in paraplegics. J Urol 1975;114: Donovan WH, Clowers DE, Kiviat MD, Macri D. Anal sphincter stretch: a technique to overcome detrusor-sphincter dyssynergia. Arch Phys Med Rehabil 1977;58:320-4.

5 1752 URODYNAMIC RESPONSES TO ANAL STRETCH IN DSD, Huang 6. Low AI, Donovan WD. The use and mechanism of anal sphincter stretch in the reflex bladder. Br J Urol 1981;53: O Shaughnessy EJ, Clowers DE, Brooks G. Detrusor reflex contraction inhibited by anal stretch. Arch Phys Med Rehabil 1981; 62: Sundin T, Carlsson CA, Kock NG. Detrusor inhibition induced from mechanical stimulation of the anal region and from electrical stimulation of pudendal nerve afferents. An experimental study in cats. Invest Urol 1974;11: Rodriquez AA, Awad E. Detrusor muscle and sphincteric response to anorectal stimulation in spinal cord injury. Arch Phys Med Rehabil 1979;60: Shafik A. Ano-vesical reflex: role in inducing micturition in paraplegic patients. Paraplegia 1994;32: Abrams P, Feneley R, Torrens M. Urodynamics. Berlin: Springer- Verlag; Yalla SV, McGuire EJ, Elbadawi A, Blaivas JG. Neurourology and urodynamics: principles and practice. New York: Macmillan; Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984;132: Perrouin-Verbe B, Labat JJ, Richard I, Mauduyt de la Greve I, Buzelin JM, Mathe JF. Clean intermittent catheterisation from the acute period in spinal cord injury patients. Long term evaluation of urethral and genital tolerance. Paraplegia 1995; 33: Mundy AR, Stephenson TP, Wein AJ. Urodynamics: principles, practice and application. 2nd ed. New York: Churchill Livingstone; Plevnik S, Janez J. Urethral pressure variations. Urology 1983; 21: Feldman M, Friedman LS, Sleisenger MH. Gastrointestinal and liver disease: pathophysiology/diagnosis/management. 7th ed. Philadelphia: WB Saunders; Suppliers a. Medtronic Urology, Dantec Medical A/S, Tonsbakken 16-18, Skovlunde, Denmark DK b. Version 8.0; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL

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