Urodynamics in Neurological Lower Urinary Tract Dysfunction. Mr Chris Harding Consultant Urologist Freeman Hospital Newcastle-upon-Tyne
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1 Urodynamics in Neurological Lower Urinary Tract Dysfunction Mr Chris Harding Consultant Urologist Freeman Hospital Newcastle-upon-Tyne
2 Learning Objectives Review functional neurology relevant to lower urinary tract Special practical considerations for the neurologically impaired patient Identify abnormalities on cystometry and relate to site of neurological lesion Guidance on structured reporting of complex urodynamic problems
3 Lower Urinary Tract Function KEEP IT SIMPLE Storage of urine at low pressure with an adequate capacity Efficient social voiding to completion
4 Normal Function
5 Lower Urinary Tract Structure Bladder Urethra Sphincter Nerve Supply
6 Nerve Supply: Overview Storage / Voiding Response Higher centres Pontine micturition centres Ascending/descending spinobulbar pathways +ve -ve -ve +ve Sacral micturition centre Pelvic plexus +ve -ve
7 Technique (1) THINK! Before you start. What do I need to know What can the patient do What help have I got What abnormalities are most likely
8 Technique (2) Filling Standard fill/slow fill Repeat with slower fill if action too quick Screen during filling with cough/valsalva Voiding lying, sitting, standing Screen upper tracts for reflux Simultaneous screen/pressure/emg for DSD Ambulatory Natural Filling
9 Pontine Micturition Centre Location, location, location Supra Pontine Supra Sacral Sacral Micturition Centre Infra Sacral
10 Loss of Inhibition Supra Pontine Detrusor Overactivity Reduced cystometric capacity Detrusor overactivity incontinence Co-ordinated Voiding Normal sphincteric action (NO dyssynergia) Complete bladder emptying No Risk to Upper Tracts
11 Stroke
12 Brain Injury
13 Supra Sacral Loss of Inhibition Detrusor overactivity Reduced cystometric capacity Detrusor overactivity incontinence Loss of Co-ordinated voiding Detrusor - sphincter dyssynergia Residual urine Loss of Sensation Unaware of leak Unaware of distension Risk of Upper Tract Dilatation
14 Spinal Multiple Sclerosis
15 Cervical Cord MS
16 Detrusor-Sphincter Dyssynergia (DSD)
17 Infra Sacral Loss of Sensation Increased cystometric capacity Loss of Motor Function No detrusor contraction (acontractile) Fixed sphincter Abnormal Voiding Straining pattern Incomplete emptying Later Changes Low compliance Risk to upper tracts
18 Central Disc Prolapse (Cauda Equina Syndrome)
19 L5/S1 Disc Prolapse
20 Mixed Picture Disease at Multiple Sites: MS Disease at Sacral or Pontine Centres: Meningomyelocele Partial Lesions: Sacral Fracture Secondary Smooth Muscle Changes
21 MS: Mixed picture
22 Meningomyelocele: Mixed picture
23 Summary History & Examination (adequate referral request) Rough idea of site and completeness of lesion Careful technique Repeat cycles until happy (don t accept poor recording) Comment on what you see (avoid overinterpretation)
24 Sensation Reduced Absent Storage Report (1) Phasic activity (neurogenic detrusor overactivity) Low compliance Detrusor Leak Point Pressure Incontinence With detrusor contraction (detrusor overactivity incontinence) Urodynamic stress (beware low opening pressure, Leak Point Pressures Abdominal, Valsalva,
25 Report (2) Voiding No voluntary void Straining Involuntary Incomplete (detrusor underactivity) Absent (acontractile) Detrusor-Sphincter Dyssynergia
26 Report Summary Abnormalities of Storage Abnormalities of Voiding Radiographic (structural) abnormalities
27 Imaging - Video
28 Summary Know a functional classification of urodynamic consequences of neurological lesions Be prepared What is likely What does the clinician need to know What can the patient cope with Strive to get full information in one go Give a structured methodical report
29 QUESTIONS?
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GBM8320 Dispositifs Médicaux Intelligents Electrostimulation Part 3: Bladder dysfunctions Mohamad Sawan et al Laboratoire de neurotechnologies Polystim!!! http://www.cours.polymtl.ca/gbm8320/! mohamad.sawan@polymtl.ca!
URODYNAMICS. Your urodynamic study is scheduled at the Ambulatory Procedure Center. This is located at 4-South waiting room at the Altru Main Clinic.
Altru HEALTH SYSTEM URODYNAMICS Your urodynamic study is scheduled at the Ambulatory Procedure Center. This is located at 4-South waiting room at the Altru Main Clinic. Arrival Time: Appointment Date: