Prepared byDr. Abdullah Ghazi (R4)

Supervised by Dr. Ali Binmahfooz

1/12/2010 KFSH&RC

Subject

Anatomy and physiologyClassification of neurogenic LUTS.Evaluation.Management.

Anatomy and Physiology

Neuroanatomy of Voiding

Neuroanatomy of VoidingFrontal lobe

Micturition centerSends inhibitory signals

Pons (Pontine Micturition Center)Excitatory centerCoordinates urinary sphincters and the bladder

Spinal cordIntermediary between upper and lower control

Peripheral Nervous SystemSomatic (S2-S4)

Pudendal nerves Excitatory to external

sphincter

Parasympathetic (S2-S4)Pelvic nerves

Excitatory to bladder, relaxes sphincter

Sympathetic (T10-L2)Hypogastric nerves to

pelvic ganglia Inhibitory to bladder,

excitatory to urethra

Normal VoidingSNS primarily controls bladder and the IUS

Bladder increases capacity but not pressureInternal urinary sphincter to remain tightly closedParasympathetic stimulation inhibited

Somatics (pudendal N) regulateExternal urinary sphincterPelvic diaphragm

PNSImmediately prior to PNS stimulation, SNS is

suppressedStimulates detrusor to contractPudendal nerve is inhibited external sphincter opens

facilitation of voluntary urination

Pathophysiology of VoidingBrain lesion above pons destroys master

control centerStroke (35%)Brain tumor (24%).Hydrocephalus (22%).CP (35%).Mental retarted (50%)Basal ganglia pathology (40%)

Result : urge incontinence. night incontinence. coordinated sphincter

Pathophysiology of VoidingSpinal cord.

Spinal cord lesion (95%).Myelomeningocele (50%DSD).Multiple Sclerosis (70%).

Result: Detrusor hyperreflexia &

spastic bladder. Detrusor Sphincteric Dyssynergia. Some: Areflexic bladder

Pathophysiology of VoidingLumbosacral spinal lesion

Spinal tumor.Herniated disc (50%).Lumbar laminectomy (50%).Radical hysterectomy.Pelvic traumaResult – areflexic bladder

Pathophysiology of VoidingPeripheral nerve injury

Diabetes (50-25%).Polio.Alcohol abuseGBS.

Classification (Madersbacher)

HistoryGeneral historySpecific history

Urinary historyBowel history:Sexual historyNeurological history

Examination

Sensation S2-S5 on both sides of the bodyReflexesAnal sphincter tone

InvestigationUrinalysisBlood chemistryVoiding diaryResidual urine (UFM).Quantification of urine loss by pad testing if

appropriateUrinary tract imaging studiesUrodynamic study.

Finding at UrodynamicFilling phase

Hyposensitivity or hypersensitivityVegetative sensationsLow complianceHigh capacity bladderDetrusor overactivity, spontaneous or

provokedSphincter acontractility.

Finding at UrodynamicVoiding phase

Detrusor acontractilityDSDNon-relaxing urethraNon-relaxing bladder neck

GUIDELINES FOR URODYNAMICS AND URO-NEUROPHYSIOLOGYUrodynamic investigation is necessary to document the

dysfunction of the LUT (A).The recording of a bladder diary is advisable (B).Non-invasive testing is mandatory before invasive

urodynamics is planned (A).Video-urodynamics is the gold standard for invasive

urodynamics in patients with NLUTD. If this is available, then a filling cystometry continuing into a pressure flow study should be performed (A).

A physiological filling rate and body-warm saline must be used (A).

Specific uro-neurophysiological tests are elective procedures (C).

Mnagement

Treatment Priority

1. Protection of the upper urinary tract2. Improvement of urinary continence3. Restoration of (parts of) the LUT function4. Improvement of the patient’s quality of life.

Goal of TreatmentIn patients with high detrusor pressure

(detrusor overactivity, low detrusor compliance, DSD, other causes of bladder outlet obstruction).

Aim to conversion high-pressure bladder into a passive low-pressure reservoir despite the resulting residual urine.

Non-invasive Conservative TreatmentAssisted bladder emptying, Credé, Valsalva.Lower urinary tract rehabilitation

Behavioural modification techniques Pelvic floor muscle exercises Pelvic floor electrostimulation Biofeedback

Drug treatment Anticholinergic agents Phosphodiesterase inhibitors, desmopressin. Cholinergic drugs (bethanechol chloride). Alpha-blockers. Increasing bladder outlet resistance (no puplish).

Electrical neuromodulationExternal appliances

GUIDELINES FOR NON-INVASIVE CONSERVATIVE TREATMENTThe first aim of any therapy is the protection

of the upper urinary tract.The mainstay of treatment for overactive

detrusor is anticholinergic drug therapy (A)Lower urinary tract rehabilitation may be

effective in selected cases.Condom catheter or pads may reduce urinary

incontinence to a socially acceptable situation.Any method of assisted bladder emptying

should be used with the greatest caution (A).

Minimal Invasive TreatmentCatheterizationIntravesical drug treatmentIntravesical electrostimulationBotulinum toxin injections in the bladderBladder neck and urethral procedures

Botulinum toxin sphincter injectionBalloon dilatationSphincterotomyStentsBladder neck incision Increasing bladder outlet resistance

GUIDELINES FOR CATHETERIZATIONIntermittent catheterization is the standard treatment

for patients who are unable to empty their bladder (A).Patients should be well instructed in the technique

and risks of IC.Aseptic IC is the method of choice (B).The catheter size should be 12-14 Fr (B).The frequency of IC is 4-6 times per day (B).The bladder volume should remain below 400 mL (B).Indwelling transurethral and suprapubic

catheterization should be used only exceptionally, under close control, and the catheter should be changed frequently. Silicone catheters are preferred and should be changed every 2-4 weeks, while (coated) latex catheters need to be changed every 1-2 weeks. (A).

GUIDELINES FOR MINIMAL INVASIVE TREATMENTBotulinum toxin injection in the detrusor is

the most effective minimally invasive treatment to reduce neurogenic detrusor overactivity (A).

Sphincterotomy is the standard treatment for DSD (A).

Bladder neck incision is effective in a fibrotic bladder neck (B).

Surgical TreatmentUrethral and bladder neck procedures

Urethral slingArtificial urinary sphincterFunctional sphincter augmentation (gracilis m)Bladder neck and urethra reconstruction (Extrophy)

Detrusor myectomy (auto-augmentation)Denervation, deafferentation, neurostimulation,

neuromodulationBladder covering by striated muscle (rectus m)Bladder augmentation or substitutionUrinary diversion (continent diversion,

incontinent diversion)

GUIDELINES FOR SURGICAL TREATMENTDetrusor

Overactive Detrusor myectomy is an acceptable option for the

treatment of overactive bladder when more conservative approaches have failed. It is limited invasive and has minimal morbidity (B).

- Sacral rhizotomy with SARS in complete lesions and sacral neuromodulation in incomplete lesions are effective treatments in selected patients (B).

Bladder augmentation is an acceptable option for decreasing detrusor pressure whenever less invasive procedures have failed. For the treatment of a severely thick or fibrotic bladder wall, a bladder substitution might be considered (B).

GUIDELINES FOR SURGICAL TREATMENTDetrusor

Underactive SARS with rhizotomy and sacral neuromodulation

are effective in selected patients (B). Restoration of a functional bladder by covering with

striated muscle is still experimental (4).

GUIDELINES FOR SURGICAL TREATMENTUrethra

Overactive (DSD): like minimal invasive treatment

Underactive The placement of a urethral sling is an established

procedure (B). The artificial urinary sphincter is very effective (B). Transposition of the gracilis muscle is still

experimental (Level of evidence: 4).

ReferanceEuropean Association of Urology 2010

M. Stöhrer, B. Blok, D. Castro-Diaz, E. Chartier-Kastler, G. Del Popolo, G. Kramer, J. Pannek, P. Radziszewski, J-J. Wyndaele

THANKS