Neuro-urodynamics Summary Neural control of the LUT Initial assessment Urodynamics Marcus Drake, Bristol Urological Institute SAFETY FIRST; renal failure, dysreflexia, latex allergy SYMPTOMS SECOND; storage, voiding, bowels, sexual 1 2 The bladder cycle Alternation between storage & voiding phases Bladder relaxed Actively inhibited Outlet contracted storage Increased contraction during physical activity; guarding and additional subtleties 3 4 and voiding. http://uroweb.org/education/learning-activities/e-learning/ Strong desire to void Anticipated circumstances Preparation of suitable environment Initiation (PMC) Adjustment Complete emptying + Detrusor contraction Outlet relaxation Termination - Premature termination 6 1
Nervous control of LUT MOTOR NEURONES Spinal cord; the lower motor neurones make muscles contract LUT motor centres (sacral cord); 1. Onuf s nucleus makes sphincter contract 2. Parasympathetic nucleus controls bladder Sympathetic nucleus (thoracic cord); makes bladder neck contract Brainstem; the upper motor neurones coordinate storage & voiding (synergy) Upper levels inhibit lower SENSORY NEURONES Receptors in bladder and urethra relay in the periaqueductal grey (PAG) and on to the brain BRAIN; sensation, decision-making 8 Possible effects on urinary function» Lower spinal cord/ peripheral nerve problems Lower motor neurone lesions affecting contraction Retention (bladder denervation), stress incontinence (sphincter denervation), Poorly compliant detrusor» Brain/ upper spinal cord problems; Upper motor neurone lesions affecting co-ordination/ inhibition Dyssynergia (DSD). Autonomic dysreflexia. Detrusor overactivity (DO).» Brain problems; Unaware of bladder filling, unaware of urine flow Can t initiate voiding (retention) or enuresis (voiding at inappropriate time/ place) Congenital and Acquired, stable Acquired, perinatal lesions conditions progressive Brain/ brainstem Cerebral palsy Stroke MSA Supra-sacral cord Spastic paraparesis Trauma MS Sacral spinal cord Sacral agenesis Conus injury Tumour Sub-sacral Spinal dysraphism Pelvic nerve injury Neuropathy No maturation of normal function Predictable loss of function Evolving loss of function Does an intervertebral slipped disc at L1/2 cause an upper or lower motor neurone lesion? LMNL History Assess the neurological condition Which part of the nervous system is affected? Is it a progressive neurological disease? Mobility, hand function or balance affected? Urinary tract; LUTS, continence, infections, quality of life, bladder management Pelvic organs; bowels, gynae, sexual Other aspects; medical history, medications, obstetric, prostate, do they have a carer. 12 2
Level of neurological deficit; leave it to the neurologist! Basic neurological examination Practical examination Walking, or wheel-chair (speed to toilet, ability to transfer). Contractures, Hand function Palpable bladder; post void residual Pelvic examination; Pelvic floor support- bladder, POP, anal Sensation Reflexes 13 14 Investigations MSU Flow rate and PVR Frequency volume chart U&Es/ EGFR (correction for low muscle mass) Ultrasound; renal and post void Baseline and follow up 15 16 17 18 3
ICS classification Sacral SCI; unsafe DLPP 19 20 Peripheral nerve injury; Male with Parkinson s disease, storage and voiding symptoms safe (i.e. renal function should not be at risk) 21 22 Male with Parkinson s disease [2] Why video UDS? Intraprostatic reflux- sphincter obstruction 23 24 4
Detrusor sphincter dyssynergia When there is flow, detrusor pressure drops PAbd Straining vs DSD? PVes PDet Q Flow 26 25 EMG Autonomic dysreflexia SCI patients with injury above T6. Triggered by a noxious stimulus below SCI level; often distended bladder or bowel Uninhibited thoracic spinal cord drives the distal sympathetic nervous system Pathological vasoconstriction below the injury level; hypertension, headache, anxiety Compensatory responses above the injury level; bradycardia, flushing, sweating Autonomic dysreflexia Prevention with appropriate anaesthesia Hypertension can be life-threatening Initial treatment is to relieve the cause Institute head-up position. Vasodilator, calcium antagonist or beta blocker Prevent further attacks Khastgir et al. 2007 Exp Opin Pharmacother 27 28 http://uroweb.org/education/learning-activities/e-learning/ Some useful resources [1] Abrams P, et al. A proposed guideline for the urological management of patients with spinal cord injury. BJU Int. 2008; 101: 989-94. [2] Fowler CJ, et al. A UK consensus on the management of the bladder in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2009; 80: 470-7. [3] Schafer W, et al. Good urodynamic practices: uroflowmetry, filling cystometry, and pressure-flow studies. Neurourol Urodyn. 2002; 21: 261-74. [4] Stohrer M, et al. The standardization of terminology in neurogenic lower urinary tract dysfunction: with suggestions for diagnostic procedures. ICS Standardization Committee. Neurourol Urodyn. 1999; 18: 139-58. [5] Wyndaele J.J. et al. Neurologic urinary incontinence. Neurourol Urodyn 2010; 29: 159-164 [6] EAU Guidelines Stohrer M. et al Eur Urol 2009; 56: 81-88 30 5
78 year old male; What s wrong and how might he present? Has the test been done correctly? Cases 31 32 40 year old female; What is abnormal about the detrusor contraction? 32 female; Arnold Chiari (cerebellar herniation, no hydrocephalus). UDS = reduced filling sensation, voids by pelvic floor relaxation. If she later gets SUI, would you do midurethral tape? 33 34 66 year old male; CVA (stroke) Detrusor overactivity incontinence 35 36 6