排尿障礙治療中心版權所有 Peripheral Neuropathy and Neurogenic Voiding Dysfunction...

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Peripheral Neuropathy and Neurogenic Voiding Dysfunction

Hann-Chorng KuoDepartment of UrologyBuddhist Tzu Chi General Hospital


Peripheral neuropathy

Cauda equina syndromeSacral root injuryPelvic plexus injuryDiabetes neuropathyDetrusor denervation


Consequences of peripheral neuropathy

Detrusor contractions are lostBladder becomes an acontractile sacBladder empty by abdominal straining or suprapubic compression (Crede maneuver) or catheterizationBladder sensation becomes vague


Lower urinary tract symptoms in Peripheral neuropathy

DysuriaStraining to voidFrequencyResidual urine sensationUrinary incontinence (overflow)Urinary retention


Physiology of micturition橋腦排尿中樞 PONS

胸腰髓 T10-L2

薦髓 S2,3,4

骨盆底神經陰部神經


Cauda equina lesion

Lumbar spinal injurySurgery for herniated discComplete or incomplete injury to nerve rootsDetrusor contractility is lost in complete lesionRecovery of detrusor contractility depends on severity of lesion


Diagnosis of Cauda equina lesionHistory of surgical traumaDysuria and straining to void after spine surgeryConstipation is the ruleSaddle anesthesia or paresthesiaLower extremity motor deficiency


Urodynamics of Cauda equina lesion

Detrusor areflexia at initial stage, sphincter tone is fixed (normal or weak)Bladder sensation of filling is normal or vagueBladder neck may be closed or openBladder compliance is normal initiallyPatients void by abdominal straining


Detrusor areflexia after cauda equina lesion


Isolated sphincter obstruction in cauda equina lesions


Bladder outlet in Cauda equina lesion

Bladder neck may be closed due to lack of synchronized relaxation during volitional voidingBenign prostatic enlargement may increase urethral resistanceIsolated striated urethral sphincter results in bladder outlet obstruction


Bladder outlet obstruction due to BPH in cauda equina lesion


Persistent dysuria after TURP in cauda equina lesion


Chronic LUTD afterCauda equina lesion

Bladder compliance turns lower than normalBladder sensation remains vagueIn isolated urethral sphincter obstruction the bladder neck is open and trabeculated bladder developsIn low urethral resistance, the bladder maintains a low pressure reservoir


Trabeculated and poor compliant bladder in cauda equina lesions


Obstructive uropathy in chronic cauda equina lesions


Meningomyelocele with detrusor areflexia & closed bladder neck


Cauda equina lesion with high urethral resistance & dysuria


Cauda equina lesion with low urethral resistance, normal flow


Management of NVD after Cauda equina lesion

Clean intermittent self catheterization should be instructed especially in womenSuprapubic cystostomy may be instituted in men Urecholine can increase intravesical pressure and facilitate straining to voidAlpha-blocker and striated skeletal muscle relaxant (Baclofen or diazepam)my be helpful


Surgical consideration for NVD after cauda equina lesions

Transurethral resection of prostate may be performed in patients with an enlarged prostate and increased urethral resistanceTransurethral bladder neck incision for those with a tight bladder neckIncontinence may be a complication after transurethral surgery


Sacral roots injury and NVD

After spine surgery or traumaUrodynamic changes as cauda equina lesionsTransient detrusor underactivity with normal or absent bladder sensationLower urinary tract dysfunction depends on complexity of nerve injuries


Pelvic plexus injury

Almost always trauma and iatrogenic Radical surgery for cervcal cancer and rectal cancerPelvic fracture with severe intrapelvic hematoma


Neuroanatomy of pelvic plexus


Pelvic plexus

Formed by the confluence of pelvic parasympathetic nerves with sympathetic hypogastric nervesPelvic plexus contains ganglia where parasympathetic nerves and sympathetic nerves interact synchronously One side pelvic plexus injury does not influence voiding function


The Pelvic Ganglia

往橋腦排尿中樞

T10-L2 髓

薦髓 S2,3,4 逼尿肌核SIN

副交感神經節

尿道外括約肌


Location of pelvic plexus

In men, posterior plexus lies close to the anterolateral wall of lower rectum and anterior plexus at posterolateral aspect of prostate and seminal vesiclesIn women, anteromedial plexus at upper part of vagina, below broad ligament and extend to cardinal ligament


Neuroanatomy of pelvic plexus


Radical abdominal hystertectomy

Damage of plexus when excision extend to level of cardinal ligament or a long cuff vaginal excisionUreter lies above plexus, avoid ureteral injury will prevent plexus injuryLimited lymph node dissection in the side without cervical cancer reduces postoperative voiding problem


Rectal cancer surgery

Pelvic plexuses are vulnerable to injury during radical rectal surgeryPelvic plexuses share the same fascial sheath with the lower rectumPudendal nerve may be damaged concomitantly during abdominoperineal resection of rectum (APR)


Neuroanatomy of Pudendal nerves


Consequences of pelvic plexus injury

Parasympathetic decentralization and leave the ganglia in the plexus or detrusor musclesSympathetic denervation and loss of coordinated regulation with parasympathetic nervesSensory afferent nerves injury and loss of awareness of bladder filling


Urodynamic changes after pelvic plexus injury

Detrusor areflexia immediately after injuryBladder sensation becomes vague and through peritoneal layer sensationThe bladder neck is loose and can be opened by increased intravesical pressureUrethral sphincter tone may not change


Urodynamic changes after radical hysterectomy

Recovery of detrusor contractility is usually incomplete & takes 6-12 monthsSignificant residual urine in the women with lower abdominal straining pressureBladder neck incompetence and isolated sphincter obstructionUrethral sphincter EMG activity may synchronously increased at bladder filling


Changes in bladder compliance after radical hysterectomy

A(n=47)

B(n=47)

C (n=47)

D (n=47)

P value<0.05 >0.05

Residuum(ml)

6.61±1.03 289.57±24.95* 140.83±19.90 65.74±11.42

A － BA － CA － DB － CB － DC － D

Rest. P.(cm H2O)

12.17±0.70 10.91±0.67 10.83±0.65 18.53±0.76A － D A － BB － D A － CC － D B － C

FSF (ml) 126.05±6.56 249.57±15.15b

215.33±15.36c

300.51±15.56d

A － B B － CA － CA － DB － DC － D

Capacity (ml)

268.51±11.48 334.04±12.81 353.33±11.67 380.42±17.65

A － B B － CA － C C － DA － DB － D

Compliance (ml/cm H2O)

53.51±6.28 7.29±0.96 13.33±1.61 19.17±2.56

A － B C － DA － CA － DB － CB － D


Large compliant and hypotonic bladder after radical hysterectomy


Detrusor areflexia and large bladder compliance after radical hysterectomy


Fair compliant and normotonic bladder after radical hysterectomy


Persistent poor compliant bladder after radical hysterectomy


Poor bladder compliance after Radical hysterectomy


Changes in urethral closure pressure after radical hysterectomy

MUCP (cm H2O) FPL (cm)

A 84.14±3.75 2.96±0.10B 60.21±3.20 2.65±0.10C 52.0±1.77 2.79±0.09D 78.08±3.86 3.09±0.01

P valueA-B,A-C,B-D,C-D<0.05A-D,B-C >0.05

A-B,A-C,B-D,C-D<0.05A-D,B-C >0.05


Lower urinary tract dysfunction after radical hysterectomy

Dysuria and straining to voidUrinary stress incontinence due to low bladder compliance or reduced bladder outlet resistance ( bladder neck incompetence or urethral sphincter insufficiency)Upper tract deterioration in chronic cases


Isolated sphincter obstruction after radical hysterectomy


Poor bladder compliance with low urethral resistance


Incontinence in Poor bladder compliance with relaxed urethral sphincter


Normal bladder compliance with low urethral resistance and SUI


Complications of pelvic plexus injury

Large residual urineFrequent urinary tract infectionOverflow incontinenceHydronephrosisAzotemia and renal scarringEnd stage renal failure


Upper tract deterioration after Radical hysterectomy

Chronic urinary retention and poor bladder compliancePatients suffer from incontinence, frequent cystitis, frequent pyelonephritisOccur when radiotherapy was performed in addition to radical hysterectomyA tight urethral sphincter is present


Contracted bladder with Bilateral VU reflux


Management of LUTD after pelvic plexus injury – Difficult urination

Behavior therapy – timed voidingMedication – urecholine, alpha-blocker, striated muscle relaxant, nitric oxide donors Clean intermittent catheterizationPeriurethral injection of botulinum toxin


Botulinum toxin A urethral injection

Dysuria after radical hysterectomy results from detrusor underactivity and a hypertonic urethral striated sphincterBotulinum toxin A exerts a paralytic effect on striated muscle50 to 100 units botulinum toxin is effective in reducing sphincteric tone and facilitate voiding by abdominal straining


Reduced voiding pressure after botulinum A toxin injection


Reduction in MUCP after Botulinum A toxin injection


Management of LUTD after pelvic plexus injury -- Incontinence

Behavioral therapy – timed voiding according to urodynamic resultsMedication – methylephedrine, imipramineSurgery – periurethral collagen or Teflon injectionSurgery – pubovaginal sling procedureUrinary diversion – Kock pouch, ileal conduit, ureterostomy, nephrostomy


Management of LUTD after pelvic plexus injury – mixed dysuria and incontinence

Urodynamic evaluation of upper tract dysfunctionIncontinence should not be treated in a poor compliant bladderClean intermittent catheterization after anti-incontinence surgery is feasibleWeigh the need of patient and side effects after management


Management of LUTD after pelvic plexus injury -- hydronephrosis

Bilateral hydronephrosis develop in chronic poor bladder complianceClean intermittent catheterization in patients with fair bladder capacityAugmentation cystoplasty to treat patients with both hydronephrosis and incontinenceCISC may be necessary after bladder augmentationAvoid surgery if Cr >2.5 or CCr<10ml/min


Improved in hydronephrosis after augmentation cystoplasty


Lower urinary tract dysfunction after radical rectal surgery

Urinary retention – detrusor areflexia or underactivity after surgeryUrinary incontinence – urethral sphincter insufficiency due to pudendal nerve injuryOverflow incontinence and poor bladder compliance are not common findings


Videourodynamic study after Abdominoperineal resection of Rectum


Lower urinary tract dysfunction after radical rectal surgery

Dysuria and large residual urine – detrusor areflexia or underactivityCombined with bladder outlet obstruction such as BN dysfunction or benign prostatic enlargementCystocele formation after APR – lack of posterior support


Treatment of difficult urination or incontinence after APR

Dysuria may be treated with Crede maneuver, intermittent catheterization, or alpha-blockerIncontinence may be treated with periurethral collagen or Teflon injection, sympathomimetic agentAvoid prostatectomy in patients with detrusor areflexia, incontinence might be a postoperative complication

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