General Neuro-urologyDiagnostics

Marcus DrakeBristol Urological Institute

Summary• Neural control of the LUT• Initial assessment• Urodynamics

Safety comes before symptoms;• Renal failure (DSD, poor compliance), autonomic dysreflexia,

latex allergy• Symptoms; LUTS, bowels, sexual

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EAU; Initial Management of Neurogenic Urinary IncontinenceHISTORY

LEVEL OF LESION Suprapontine cerebral lesion (e.g.

Parkinson’s disease, stroke, multiple sclerosis)

Suprasacral infrapontine spinal cord lesion

(e.g. trauma, multiple sclerosis)

Peripheral nerve lesion (e.g. radical pelvic surgery)

Conus /cauda equina lesion (e.g. lumbar disc prolapse)

CLINICAL ASSESSMENT • Further history• General assessment including home assessment

• Urinary diary and symptom score• Assessment of functional level, quality of life and desire for treatment

• Physical examination: assessment of sensation in lumbosacral dermatomes, anal tome and voluntary contraction of anal sphincter, bulbocavernosus and anal reflexes, gait

• Urine analysis + culture (if infected, treat as necessary)• Urinary tract imaging, serum creatinine: if abnormal: specialised management• Post void residual (PVR) by abdominal examination or optional by ultrasound

These will give basic information, but do not permit a precise neurological diagnosis

Stress urinary incontinence due to sphincter incompetence

PRESUMED DIAGNOSIS

• Intermittent catheterisation with or without

• Antimuscarinics

• Behavioural modification• External appliances

TREATMENT

NECESSARY IN ALL

Specialised management preferable for more ‘tailored’ treatment

Poor bladder emptying (significant PVR)

• Depending on cooperation and mobility:

• Behavioural modification• Antimuscarinics

• External applicances• Indwelling catheter

With negligible PVR

Urinary incontinence due to sphincter overactivity

Failure FailureFailure

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Brain; sensation, decisions (volition) Brainstem; co-ordinates storage &

voiding (synergy) Spinal cord;

– Blood pressure, ejaculation (SNS motor nucleus)

– Bladder contraction (PNS nucleus)– Outlet contraction/ relaxation (Onuf) – Sacral cord mediates voiding in infants

Peripheral nerves; efferents/ afferents Upper levels inhibit lower

Nervous control of LUT

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» Unaware of filling/ flow. Can’t initiate void. Enuresis

» Dyssynergia (DSD). Detrusor overactivity (DO)

» DO, DSD» Hyperreflexia

» Detrusor areflexia, SUI, poor compliance

» Areflexia, SUIPeripheral

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EAU GUIDELINES HISTORY• Past history• Childhood – adolescence – adult. Hereditary or familial risk factors Menarche (age); may suggest metabolic disorder. Obstetric

history. History of diabetes; in some cases correction will resolve the neurological problem. Diseases, e.g. syphilis, Parkinsonism, multiple sclerosis, encephalitis. Accidents and operations, especially those involving the spine and CNS

• Present history• Medication. Lifestyle (smoking, alcohol and drugs); may influence bowel and urinary function. Quality of life. Life expectancy• Specific urinary history• Onset urological history. Relief after voiding; to detect the extent of a neurological lesion in the absence of obstructive uropathy.

Bladder sensation. Initiation of micturition (normal, precipitate, reflex, strain, Credé). Interruption of micturition (normal, paradoxical, passive). Enuresis. Mode and type of voiding (catheterisation)

• Urinary diary; (semi)objective information about number of voids, day- and night-time voiding frequency, volumes voided, incontinence, urge episodes

• Bowel history• Frequency and faecal incontinence. Desire to defecate. Defecation pattern. Rectal sensation. Initiation of defecation (digital

rectal stimulation)• Sexual history• Genital or sexual dysfunction symptoms. Sensation in genital area. Specific male: erection, (lack of) orgasm, ejaculation. Specific

female: dyspareunia, (lack of) orgasm• Neurological history• Acquired or congenital neurological condition. Mental status and comprehension. Neurological symptoms (somatic and sensory),

with onset, evolution and any treatment. Spasticity or autonomic dysreflexia (lesion above level Th 6). Mobility and hand function

History- simplified

Assess the neurological condition• Which part of NS affected? Is the disease

progressive?• Mobility, hand function, autonomic

Assess the urinary tract; LUTS, continence, UTIs, QoL, current bladder management

Pelvic organs; bowels, gynae, sexual Assess the rest of patient; medical history,

medications, obstetric, prostate….

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EAU GUIDELINES- EXAMINATION Sensations S2-S5 (both sides)

– Presence (increased/normal/reduced/absent). Type (sharp/blunt)– Afflicted segments

Reflexes (increased/normal/reduced/absent)– Bulbocavernous reflex. Perianal reflex– Knee and ankle reflexes– Plantar responses (Babinski)

Anal sphincter tone– Presence (increased/normal/reduced/absent)– Voluntary contractions of anal sphincter and pelvic muscles

(increased/normal/reduced/absent) Prostate palpation. Descensus (prolapse) of pelvic organs

Examination- practical

Walking, or wheel-chair (speed to toilet, ability to transfer). Contractures.

Hand function (ISC- do they have a carer (CIC)) Palpable bladder; post void residual Pelvic examination;

– Pelvic floor support- bladder, POP, anal– Sensation– Reflexes

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Basic neurological examination

Level of neurological deficit; usually specified by the neurologist

Investigations Urinalysis/ MSU Flow rate and PVR Frequency volume chart U&Es/ EGFR (correction for low muscle mass) Ultrasound; renal and post void

Assessed at baseline and follow up

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Flow rate & residual

POST VOID RESIDUAL; UTIs, Incontinence(Sensation of fullness- only if the patient’s afferents function)

(Renal failure- if bladder is poorly compliant &/or there is reflux)

Urodynamics; orientation

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Non-neuropathic; DO at 08.15 and 09.15, cough-provoked DO 10.30,voids on overactive contraction, small cystometric capacity

Urodynamics in neuropaths• What information should it give us? 1. Is the

patient’s renal function safe?– Dysynergia, poor bladder compliance, reflux

2. How to manage symptoms– Storage, voiding, bladder/ outlet

• Technical points (Good Urodynamic Practice; Schafer et al., Neurourol Urodyn 2002)– Slow filling– Video preferred– Dangers; autonomic dysreflexia, latex allergy

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Classic patterns LMNL- unsafe (sacral injury)

– Outlet failure, reduced compliance, straining, reduced sensation

LMNL- safe (peripheral injury)– Outlet failure, straining, (reduced sensation)

UMNL– Detrusor overactivity (incontinence)– DSD if spinal cord/ brainstem, enuresis if cerebral– PVR– Reduced sensation

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International Continence Society classification of LUT lesions

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DLPPSacral SCI; unsafe LMNL

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DLPP In poorly compliant bladder, detrusor pressure at which

leakage occurs (involuntarily) A crucial element of assessing long-term risk to renal function

in neuropathic patients (>40cmH2O in spina bifida, maybe >25)

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VLPP The pressure at which a patient leaks when

he/ she does a series of valsalvas of increasing strength

Measures sphincter deficiency

Peripheral nerve injury;

“safe” LMNL (i.e. renal

function should not be at risk)

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Detrusor sphincter dysynergia Pons determines reciprocal activity of outlet and bladder;

“synergy”– Lost if lesion between brainstem/ sacral cord

Effects; high pressures during voiding, raised PVR, UTI, renal failure

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Straining vs DSD

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PAbd

PVes

PDet

Q Flow

EMG

Detrusor sphincter dyssynergia When there is flow, detrusor pressure drops

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Why video UDS? Male with Parkinson’s disease and voiding symptoms

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Male with Parkinson’s disease [2]

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Why video UDS?Intraprostatic reflux- indicating

sphincter obstruction

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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

Khastgir et al. 2007 Exp Opin Pharmacother 31

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

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Latex and spina bifida

Spina bifida patients at high risk Can result in anaphylaxis Patients with known sensitivity should be

managed under appropriate protocol Routine testing is not in current use in UK

Neural control of the LUT Initial assessment Urodynamics

DSD, autonomic dysreflexia, poor compliance SAFETY FIRST, SYMPTOMS SECOND

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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] Khastgir J, et al. Recognition and effective management of autonomic dysreflexia in spinal cord injuries. Expert Opin Pharmacother. 2007 May;8:945-56

[7] EAU Guidelines Stohrer M. et al Eur Urol 2009; 56: 81-8835

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