Urodynamic and electrophysiological investigations in neuro-urology Pr. Gerard Amarenco Neuro-Urology and Pelvic-Floor Investigations Department Tenon Hospital, Assistance Publique Hôpitaux de Paris, Er6, UPMC ESPRM, Venice, May 27, 2010
Neuro-urology is a very important activity of specialists in PMR... Spinal cord injury Parkinson 100 ms Spina Bifida Multiple sclerosis
URODYNAMIC vs ELECTROMYOGRAPHY UD : best way to precise pathophysiology Emg: 100 ms best tool to precise etiology and level Vesical pressure Pressure 3-way stopcock Volume Water Column - Torricelli 1608-1647
General organization of the nervous system Storage and micturition : controlled by autonomic and somatic innervations Pontine micturition center sacral parasympathetic pathways : pelvic nerve ; thoracco-lumbar sympathetic pathways : hypogastric nerve ; sacral somatic pathways with pudendal nerve.
Many reflexes control the storage phase and the micturition. Urine storage dependant on spinal reflexes : the efferent pathways are the somatic nerves (external sphincter contraction) and the sympathetic nerves (internal sphincter contraction, detrusor inhibition) Pontine micturition center (M region) Pontine continence center (L region) PMC is connected with the sacral cord via ascending and descending pathways Micturition : under control of spinobulbospinal reflexes which determine inhibition of sympathetic activity and activation of parasympathetic activity (detrusor contraction). consists of a synergic action between the detrusor and sphincter controlled PMC Stimulation of M region determines a complete and coordinated micturition S2-S4 L region is implicated in the control of continence and tonic control of the sphincter
Diagnosis : normal cystometry Guarding reflex : increase of emg relaxation of US during voiding Volume EMG Pura Pves Pdet Pabd EMG Qura l l l l l l l 0 100 200 300 400 500 600 Volume ml Time Storage Phase CP RELAX Voiding Phase
Ice water test Overactive detrusor Underactive detrusor
Urodynamic evaluation (cystometry) criteria : - maximum detrusor pressure - maximum detrusor pressure during micturition - duration of detrusor pressure > 30 cmh2o - maximum capacity - vol 1st Uninhibited detrusor contraction C y s t o P R 1 0 0 m l E M G # 2 E M G u V 2 0 0 1 0 0 P v e s c m H 2 O 0 4 0 2 0 Toux Toux Toux Toux P a b d c m H 2 O 0 4 0 2 0 V i n f u s m l 0 4 0 0 2 0 0. = 101 ml 0 T T P B T B 1 O D M S T. C M 3 0 s 0 0 : 0 0 0 1 : 0 0 0 2 : 0 0 0 3 : 0 0 T
Detrusor-Sphincter Dyssynergia (DSD) involuntary contraction of the detrusor accompanied by an involuntary contraction of the external sphincter Complications : kydneis (reflux, hydronephrosis, renal failure) and bladder Spinal cord injury (70-100%) Multiple sclerosis (30-80%) very common problem more frequent in medullaris lesions (SCI/MS) than encephalic one
Detrusor sphincter dyssynergia normal PMC paraplegic detrusor contraction micturition emg increase DSD Patho physiology DSD = involuntary contraction of the detrusor accompanied by an involuntary contraction of the external sphincter
Therapeutic interest : to verify efficacy before after
after before
Gallien P, 2005 Intrasphincteric injection of Botox => reduces maximal detrusor pressure
Urodynamic & neurogenic bladder : CONCLUSIONS very important tool to precise pathophysiology evaluation of the prognosis control of medical (or surgical) treatment rarely diagnostic interest
In all the cases and always before emg clinical uro-gynecological and neurological examination
Kinesiological EMG : to explore activation patterns of pelvic floor Stress urinary incontinence : alteration of muscular component (pudendal neuropathy, conus medullaris syndrome) Surface electrodes 250 400 60 300 200 200 50 150 100 100 0-100 -200 VP EMG [uv] 40 30 20 Pabd [cmh2o] Pves [cmh2o] EMG SAE [uv] 50-300 10-400 0-500 0 620 ms cough not a simple spinal reflex..
Therapeutic interest of emg Injection with emg guidance 70 100 UI BOTOX Diluted in 4 ml of 0.9% saline Schurch : 3 successive injections of 250 IU at 1 month Injection : transurethral or transperineal route
Pelvic floor muscles in woman
Electromyography Urethral Sphincter m. Bulbocavernous Urethral Sphincter Recording EMG Anal Sphincter
electromyography The examination is conducted usually with a single use, disposable electrode. EMG is used to differentiate between normal, denervated, reinnervated, and myopathic muscle. Neurogenic changes may be attributable to injury at any level along the lower motor neuron supplying the perineal muscles, extending from the sacral nerve roots to the distal branches of the pudendal nerve. 100 ms 20 ms 5 ms MUP Motor Unit Striated Muscle 1 2
Electromyography By analysing the interference pattern By analysing motor unit potentials (MUPs) EMG can provide information on : - insertion activity, - abnormal spontaneous activity - MUPs - interference pattern +++ The amount of recruitable motor units during voluntary and reflex activation can also be estimated. Normally, MUPs should intermingle to produce an "interference" pattern on the oscilloscope during muscle contraction, and during a strong cough
Motor Unit Potential (MUP) Single Potential, Phases < 3 Polyphasic Potential, Phases > 3 Segment Turns Amplitude Phase Baseline Crossing Satellite Group of Muscle Fibers generate MUPs. Different Fibers different MUPs. Rising Time Duration 7 Turns 3 Phases 6 Segments
MUP Analysis Multi-MUP - Averaging Manual Selection Single - Triggering Moderate Contraction Simple/Polyphasic Potentials Ratio Amplitude Duration
1 seconde EMG signal Concentric or Monopolar Needle Turns/Amplitude Few sites in same muscle 20 measurments at diff. force Number of Turns > 100 µv Mean Amplitude of Turns Myopathy Amplitude Turns T2 A = Amplitude S = Segment A4 A3 A2 A1 S1 S2 T3 S3 T4 S4 Neuropathy Polio Sequele tib ant Amplitude T1 T5 Change in signal direction = Turn Segment Amplitude > 100 µv Turns
Interest of emg in neurogenic fecal incontinence Alteration of muscular component : - pudendal neuropathy - conus medullaris sd - diagnosis of neurogenic - prognosis for surgery
Interest of emg in Parkinson disease Parkinson disease Multi System Atrophy Progressive Supranuclear Palsy Dementia with Lewy Bodies Corticobasal Degeneration G. Wenning, I. Litvan and Coll., JNNP, 1999 denervation in anal/urethral sphincters
Interest of emg in C. Fowler syndrome Pseudo-myotonic discharges in striated sphincter
Bulbocavernous Reflex Stimulation Penil Nerve R1 R2 Current Stimulation Increased Recording Needle ( Needle Electrode) m. Bulbocavernous Stimulation Clitoral Nerve Recording Reflex Latency R1 typ. 33 ms Recording Surface
Bulbo-cavernosus reflex : polysynaptic reflex
Interest of bulbo-cavernosus reflex Sacrum fracture Disk herniation Sacral tumors Spinal tumors - diagnosis - prognosis
Pudendal nerve terminal motor latency Stimulation of pudendal nerve Record : anus
St Marks electrode
Record in BC muscle Record in anal muscle
PNTML : Pudendal Neuralgia
Sites of compression Ischial spine Alcock pudendal canal
Evoked Potential Normal Multiple Sclerosis Stimulation Penil Nerve Cz-2 - FPz P40 Stimulation Clitoral Nerve FPz Ground Record on Scalp with Scalp Needle or Surface Electrode Averaging : 200 2 cm Cz-2 Latency P40 (nl < 44 ms)
Sensory velocity of dorsal nerve of penis
Sympathetic Response Recording : Surface electrodes Across Penis Typ. Lat. 1,5 s Amplitude : 2-3 mv Recording : Surface electrodes Act. Vaginal Lips Ref. Pelvic area Stimulation Median nerve, Intensity 3 times sensory threshold.
Sympathetic Response Normal subject Alteration of SSR in Pudendal neuralgia?
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