THE ACONTRACTILE BLADDER - FACT OR FICTION? Jacob Golomb Department of Urology Chaim Sheba Medical Center Tel Hashomer
NEUROGENIC UNDERACTIVE DETRUSOR Central (complete/incomplete): Spinal cord injury- trauma, vascular, disc disease, spinal stenosis Spinal cord disease- myelitis, tumor, MS, spina bifida Conus medullaris injury (cauda equina syndrome)
NEUROGENIC UNDERACTIVE DETRUSOR (cont.) Peripheral- pelvic plexus injury: Trauma Infection (herpes zoster, Guillain-Barre syndrome) Pelvic tumor extending to nerves Major pelvic ablative surgery (Miles operation, low anterior resection of rectum, radical hysterectomy) Diabetic cystopathy: Decreased bladder sensation Increased capacity Impaired contractility
TREATMENT OPTIONS FOR NEUROGENIC UNDERACTIVE DETRUSOR Permanent catheter drainage Intermittent catheterization Sphincterotomy Treatment of all entities aims at adequate bladder emptying and low-pressure storage
NON-NEUROGENIC UNDERACTIVE DETRUSOR DOIC (Detrusor Overactivity with Impaired Contractility) Psychogenic urinary retention Long-standing bladder outlet obstruction Aging Idiopathic conditions
ICS Standard Urodynamic Test: Uroflowmetry and PVR plus transurethral cystometry and pressure-flow study, all performed in the patient s preferred or most usual position; usually comfortably seated and or standing if physically possible. The patient(s) may be then reported as having had an ICS standard urodynamic test (ICS-SUT).. Peter F.W.M Rosier et al: International Continence Society Standard Good Urodynamic Practices and Terms 215. Urodynamics, Uroflowmetry, Cystometry and Pressure-Flow Study. www.ics.org/documents/documentsdownload.aspx?documentid=377.
Uroflowmetry#1 3 25 Qura ml/s 2 15 1 5 4 Vura ml 3 2 1 VB MF VE 4 s :24 :32 :4 :48 :56 1:4
Uroflowmetry#1 Qura 5 ml/s 4 Uroflowmetry#1 Qura 5 ml/s 4 Vura ml 3 2 Vura ml 3 2 1 1 VB MF VE 2 s 1:2 2: 2:4 3:2 4: ST VB 15 s : :3 1: 1:3 2: 2:3 3: MF VE Uroflowmetry#1 Uroflowmetry#1 Qura ml/s 5 4 Qura ml/s 15 1 5 Vura ml 3 2 1 Vura ml 4 3 2 1 VB MF VE 8 s :56 1:12 1:28 1:44 2: 2:16 VB MF 4 s :44 :52 1: 1:8 1:16 1:24 1:32 VE
Filling & Voiding Cystometry#1 18 16 14 12 1 8 6 4 2 Uroflowmetry#1 2 15 Qura ml/s 1 ICS method p at Void Begin 3 cmh2o Pdet [cmh2o] p at Max Flow 43 cmh2o Q at Max Flow 17.8 ml/s 5 4 3 Vura ml 2 p at Min Flow 27 cmh2o p at End Flow 27 cmh2o Desc. Slope.9 cmh2o/ml/s Flow Delay.7 s A/G Unobstructed A/G# 7.6 Obstructed Equivocal Unobstructed Vura ml Pdet cmh2o Pves cmh2o Pabd cmh2o Qura ml/s 5 3 2 1 3 2 1 3 2 1 15 1 5 2 4 6 8 1 12 14 16 18 2 22 24 26 1 Qura [ml/s] 3 EMGave uv 2 1 VB MF VE 4 s :28 :36 :44 :52 1: 1:8 1:16 CC PI1 VB PI11 PI12 MF PI13 PI14 PI15 VEPI17 MP PI16 7 s 11:29 11:43 11:57 12:11 12:25 12:39 12:53
Filling & Voiding Cystometry#1 Uroflowmetry#1 Vura ml 5 3 Qura 1 Pdet cmh2o 2 1 ml/s 5 3 4 ICS method p at Void Begin 83 cmh2o Pdet [cmh2o] p at Max Flow 189 cmh2o Q at Max Flow 6.9 ml/s p at Min Flow 34 cmh2o 18 p at End Flow 17 cmh2o Desc. Slope 24.3 cmh2o/ml/s 16 Flow Delay.7 s 3 A/G Obstructed 14 A/G# 175. Vura 12 Obstructed 1 ml 2 8 Equivocal 6 1 4 Unobstructed Pves cmh2o Pabd cmh2o Qura ml/s 2 1 3 2 1 15 1 5 2 2 4 6 8 1 12 14 16 18 2 22 24 26 Qura [ml/s] EMGave uv 3 2 1 VB MF VE 6 s 1:24 1:36 1:48 2: 2:12 2:24 CC VB MP MF VE 9 s 9:54 1:12 1:3 1:48 11:6 11:24 11:42
Filling & Voiding Cystometry#1 Uroflowmetry#1 Qura ml/s Vura 12 ml 1 8 6 4 2 5 4 ICS method p at Void Begin 6 cmh2o Pdet [cmh2o] p at Max Flow 66 cmh2o Q at Max Flow 8.6 ml/s p at Min Flow 35 cmh2o 18 p at End Flow 29 cmh2o Desc. Slope 3.8 cmh2o/ml/s 16 Flow Delay.7 s A/G Obstructed 14 A/G# 49. 3 2 1 Obstructed Equivocal Unobstructed 2 4 6 8 1 12 14 16 18 2 22 24 26 Qura [ml/s] Vura ml Pdet cmh2o Pves cmh2o Pabd cmh2o Qura ml/s 5 3 2 1 3 2 1 3 2 1 15 1 5 6 EMGave 4 uv 2 VB MF VE 2 s 1:2 2: 2:4 CC PI173:2 PI19 PI2 MF PI23 4: PI25 PI16 PI18 VB PI21 15 s 9:52 1:22 1:52 11:22 11:52 PI22 PI24 MP PI26 PI27 PI28 PI3 PI29 PI31 PI32 V PI33
Mis-interpretation of urodynamic graphs
D.A., 66 years old 6 months ago AUR Following weaning from indwelling catheter he voided only small volumes US: trabeculated bladder, prostate 4 gram, PVR 75cc Urodynamics: Started SIC + Betanechol
Repeat Urodynamics
TURP
L.Y., 64 years old Voiding difficulties for the past 1 years Was treated with alpha-blockers and betanechol without improvement On SIC for the past 2 years, no spontaneous voiding US: trabeculated bladder, prostate 3 grams Urodynamics: Advised to continue SIC
TURP Uroflowmetry#1 3 25 Qura ml/s 2 15 1 5 4 Vura ml 3 2 1 VB MF VE 9 s :27 :45 1:3 1:21 1:39 1:57 2:15
W,I., 56 years old Has voiding difficulties for the past 3 years In 27 underwent BNI with symptomatic improvement for several years US: normal bladder, prostate 4 grams Cystoscopy: interpreted as normal Urodynamics: Was started on SIC
TURP
Detrusor underactivity is defined by the International Continence Society (ICS) as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 22;21:167 78. However, the ICS report falls short in specifying parameters for reduced contraction strength, prolonged bladder emptying, or normal time span. Suggested working definition: The underactive bladder is a symptom complex, and is usually characterised by prolonged urination time with or without a sensation of incomplete bladder emptying, usually with hesitancy, reduced sensation on filling, and a slow stream. Chapple CR et al. The Underactive Bladder: A New Clinical Concept?. Eur Urol 68 (215) 351-353. Based on a consensus group meeting at the International Consultation on Incontinence Research Society and ICS annual meetings in September and October 214.
IN SUMMARY: The urodynamic diagnosis of non-neurogenic detrusor underactivity in men with LUTS needs to be based on strict criteria, which are not defined yet. Permanent SIC should be applied in men with LUTS and urinary retention with utmost prudence. In non-neurogenic men with urinary retention, the options of TURP versus permanent SIC should be discussed with the patient.