Annual Scientific Update in Urogynaecology- Joint RCOG/BSUG Meeting Neurogenic bladder dysfunction

Transcription

1 Annual Scientific Update in Urogynaecology- Joint RCOG/BSUG Meeting Neurogenic bladder dysfunction Clare J.Fowler National Hospital for Neurology and Neurosurgery & Institute of Neurology, UCL

2 Aims Background Brain processing of bladder afferents Urinary retention in young women Response to sacral neuromodulation Joint Best Abstract at ICS 2009 San Francisco An fmri study of the effect of sacral neuromodulation on brain responses in women with urinary retention ICS Discussed Poster 32 The possible role of opiates in women with urinary retentionobservations from a prospective clinical study

3 PAG PMC S2-4 in cauda equina pelvic & pudendal ns

4 How full is my bladder? Is this the right time and place to void? S2-4 in cauda equina pelvic & pudendal ns

5 Fowler, de Groat and Griffith, 2008

6 Derek Griffiths Triple Circuit theory of bladder control Circuit 1

7 Derek Griffiths Triple Circuit theory of bladder control Circuit 1 and 2

8 Derek Griffiths Triple Circuit theory of bladder control Circuit 1, 2 and 3

9 ACC TH MPFC RI/LPFC H PAG PMC

10 ACC TH MPFC RI/LPFC H PAG PMC

11 PMC S2-4 in cauda equina pelvic & pudendal ns

12 Urinary retention in young women

13 Map of Referrals Of women in retention Key and Number of referrals Referrals Referrals Referrals Referrals Referrals 2006/7 83 Referrals Edinburgh Belfast Cardiff Manchester Birmingham London London (within M25) Referrals Referrals Referrals Referrals Referrals 2006/7 35 Referrals Guernsey

14 Causes for retention (n=53) 55% Cause undetermined (n=29) 9% 6% 6% Fowler's Syndrome (n=13) Chronic intestinal pseudo obstruction (n=3) Postoperative* (n=3) 25% Under investigation (n=5) *Surgeries: Anterior resection of colon, rectopexy, caudal block

15 Primary disorder of sphincter relaxation involuntary involuntary

16 Clinical History of FS Female Aged between onset of menarche and menopause No evidence of urological disease, gynaecological or neurological disease Retention with a volume in excess of >1000 ml No sense of urinary urgency despite high bladder volumes Straining does not help emptying Sense of something gripping or difficulty on removing the catheter No history of urological abnormalities in childhood or associated abnormalities of the urinary tract. Association with polycystic ovarian syndrome and endometriosis

17 Laboratory Findings Raised urethral pressure (> 50% expected value for age) Characteristic urethral sphincter EMG (Increased sphincter volume on USS assessment)

18 higher brain centres higher brain centres A PAG B PAG Sacral cord Sacral cord urethral afferents bladder afferents urethral afferents bladder afferents Pro-continence reflex

19 Response to sacral neuromodulation (SNM)

20 y Percent survival Success over time Time to recurrent retention FOWLER NON-FOWLER P=0.005 Time De Ridder et al. Eur Urol Jan;51(1):

21 PNE

22 An fmri study of the effect of sacral neuromodulation on brain responses in women with Fowler s Syndrome Rajesh Kavia, Ranan DasGupta, Hugo Critchley, Clare Fowler and Derek Griffiths

23 Fowler s Syndrome: our hypothesis We expected: weak or no bladder signals in response to bladder filling weak or no response at gateway to brain (PAG) weak or no response to bladder filling where sensation is registered (insula) normalization by SNM PAG insula

24 Methods 6 women with FS aged years had responded to temporary SNM therapy fmri with 1.5 Tesla scanner 1 scan per 3.24s, covering brain in 36 slices 280 scans in 15 min measured brain responses to repeated rapid bladder filling and withdrawal

25 Methods In each session: repeated infusion and withdrawal of 50 ml saline (over 7 s) with reporting of change in desire to void Response to filling taken as infusion minus withdrawal infuse withdraw empty full

26 Methods: 4 sessions Near-empty bladder Full bladder (> 600 ml) No SNM (baseline) With (just after) SNM

27 normal red = activated Baseline findings Fowler s syndrome blue = deactivated insula

28 Findings We expected weak or no activation but instead we find widespread brain deactivation in Fowler s syndrome the opposite of normal behavior Is this an artifact? If this is real we expect larger deactivation in more pronounced disease (higher MUCP)

29 More deactivation Test: deactivation more pronounced in patients with higher MUCP: not an artifact Higher MUCP

30 Which regions are deactivated? Right insula visceral sensory cortex deactivated PAG (or nearby) gateway to brain deactivated insula PAG

31 Effect of filling bladder and SNM fill bladder The deactivations we saw before empty bladder no SNM SNM With full bladder or after SNM more activation less deactivation More nearly normal

32 Where is activation restored by full bladder and SNM? Restored activation of PAG gateway to brain restored bladder signals and right insula seat of bladder sensation fmri PAG Patients report restored sensation (and ability to void) insula PET Older PET study showed similar PAG behavior with SNM

33 Method reminder In each session: repeated infusion and withdrawal of 50 ml saline (over 7 s) with reporting of change in desire to void Response to filling taken as infusion minus withdrawal infuse withdraw empty full

34 Suggested mechanism SNM

35 Conclusions Existing conundrum how does SNM work in DO, OAB AND retention? In Fowler s Syndrome SNM partly rectifies situation by supplying afferent input to midbrain What does blue brain before SNM in FS mean? Brain responses to bladder filling abnormal causing deactivation instead of activation Reduced bladder afferents, reduced sensation Stronger with higher MUCP

36 Opiate use in 61 patients with urinary retention Panicker, 2009, ICS San Francisco

37 higher brain centres higher brain centres A PAG B opiates PAG Sacral cord Sacral cord urethral afferents bladder afferents urethral afferents bladder afferents

38 Conclusions FS is a common cause of urinary retention in young women These patients respond particularly well to sacral neuromodulation It works by re-informing the brain about bladder sensation However, we are now alert to the possibility that opiates may have an additive effect on the pathophysiology of FS.