排尿障礙治療中心版權所有 Spinal cord injury Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital Hualien

排尿障礙治療中心版權所有

Spinal cord injurySpinal cord injury

Hann-Chorng KuoDepartment of Urology

Buddhist Tzu Chi General Hospital Hualien


Leading causes & Location of Spinal cord injury

Leading causes & Location of Spinal cord injury

Motor vehicle accidents (47%) Falls (21%) Sports (14%) Act of violence (14%) Location of SCI: cervical (53%), thoracic (35%),

lumbar and sacral (10%)


Urinary tract symptoms in Acute spinal cord injuryUrinary tract symptoms in Acute spinal cord injury

Spinal shock stage: detrusor areflexia, complete anesthesia of fullness or voiding

Recovery of micturition reflex gradually about 1-3 months after recovery of somatic reflexes

Prolonged recovery of voiding reflex may be due to overdistension of the bladder after injury or complication


Micturition ControlMicturition Control Micturition reflex center – sacral cords S 2-4 Sympathetic nucleus – T10-L1 Micturition control center – pons Sensory motor center – frontal lobe Limbic system Cerebellum, Basal ganglia


Pathophysiology of lower urinary tract dysfunction after SCI

Pathophysiology of lower urinary tract dysfunction after SCI Suprasacral cord lesion – interruption of coordin

ation of detrusor contraction and sphincter relaxation

Lesion above T6 SCI – sympathetic hyperactivity during activation of visceral input, bladder distension, rectal distention, cold and noxious stimulation, surgery and infection


Chronic spinal cord injury and urinary tract dysfunction

Chronic spinal cord injury and urinary tract dysfunction Autonomic dysreflexia – SCI above T5,6 (sympat

hetic nucleus) Detrusor external sphincter dyssynergia (DESD)

– lesion above S2-4 Detrusor hyperreflexia – complete or incomplete

SCI above sacral cords Detrosor areflexia – sacral cord SCI or cauda eq

uina lesions


Urodynamic findings in SCIUrodynamic findings in SCICervical

(n=68)

Thoracic

(n=53)

Sacral or infrasacral

(n=40)

Detrusor hyperreflexia 47(69%) 29 (55%) 2 (5%)

Detrusor areflexia 21(31%) 24 (45%) 38 (95%)

DESD

Presence 41(60%) 20 (38%) -

Absence 27(40%) 33 (62%) 40 (100%)

AD

Presence 22(32%) 1 (2%) -

Absence 46(68%) 52 (98%) 40 (100%)

DESS=Detrusor external sphincteric dyssynergia; AD=autonomic dysreflexia.


Major concern in managing SCIMajor concern in managing SCI

Preservation of renal function Free of symptomatic urinary tract infection Efficient bladder emptying Freedom of catheter Continence


High risk SCI PatientsHigh risk SCI Patients

Complete neurological lesion Cervical SCI with quadriplegia Prolonged indwelling catheter High detrusor leak-point pressure Presence of DESD and AD Large residual urine Presence of vesicoureteral reflux


Detrusor leak-point pressureDetrusor leak-point pressure The intravesical pressure (detrusor pressure) at t

he end of filling or urinary incontinence A detrusor LPP of over 40cm water will endange

r the upper tract in meningomyelocele Reduction of detrusor LPP can improve renal fun

ction, reduce the risk of UTI, decrease the degree of hydronephrosis, improve vesicoureteral reflux and restore continence


Hydronephrosis in SCIHydronephrosis in SCI Hydronephrosis is a sign of upper tract deteriorat

ion after SCI In 251 SCI patients, 24 (9.6%) had hydronephro

sis, including: Cervical SCI 7 (5.9% of 118), 7+ 4 (3-15) years Thorac& lumb 8 (8.6% of 93), 9.9+ 6.5 (3-22) Sacral 9 (22.5 of 40), 17+ 6.1 (8-26)


Autonomic dysreflexiaAutonomic dysreflexia Spinal cord lesion above T6 Hypertension and increased sympathetic

outflow, flushing, sweating above dermatome during increased visceral input (bladder over-distension,urination, rectal distension, surgery, UTI)

Risk of heart failure and stroke Bladder neck contraction during voiding


Cervical SCI autonomic dysreflexia and BN dysfunction Cervical SCI autonomic dysreflexia and BN dysfunction


Detrusor external sphincter dyssynergia (DESD)Detrusor external sphincter dyssynergia (DESD) Spinal cord lesion above micturition reflex center Lack of coordination in the micturition center External sphincter contrction during detrusor con

tractions Dysuria, difficult to initiate voiding, high voiding p

ressure, large residual urine Result in frequent UTI and upper tract damage


Grades of DESDGrades of DESD Grade 0- 3 according to the sphincteric activity Grade 0 – normal or synergia Grade 1 – DH &high Pves, hyerreflexic sphincter at initi

ation, voiding with mild residual urine Grade 2 – DH or hyporeflexic detrusor, intermittent hype

rreflexic sphincter, large residual urine Grade 3 – DH, closed hyperreflexic sphincter, no sponta

neous voiding


Grade 1 DESDGrade 1 DESD


Grade 2 DESD- High voiding pressure and increased EMG

Grade 2 DESD- High voiding pressure and increased EMG


Gr 2 DESD with low voiding pressure and no flowGr 2 DESD with low voiding pressure and no flow


Grade 3 DESDGrade 3 DESD


Recovery from spinal shock in Cervical SCI Recovery from spinal shock in Cervical SCI


Late Urological Complications in Spinal cord injury

Late Urological Complications in Spinal cord injury

Urinary tract infection induced sepsis Hydronephrosis and uremia Stone formation (renal& bladder stone) Contracted bladder & VU reflux Incontinence and associated complications Bladder tumor formation (chronic indwelling cath

eter)


Hydronephrosis in chronic SCIHydronephrosis in chronic SCI


Bladder stones in chronic SCIBladder stones in chronic SCI


Vesicoureteral reflux in chronic SCIVesicoureteral reflux in chronic SCI


Analysis of LUTS in 704 SCI Analysis of LUTS in 704 SCI

頸髓脊髓損傷胸髓脊髓損傷腰髓脊髓損傷薦髓及以下脊髓損傷

完全不完全完全不完全完全不完全完全不完全

尿瀦留 14 5 12 3 3 3 0 2尿失禁（無感覺） 50 18 92 14 31 13 2 3

尿失禁（有感覺） 27 32 24 12 14 14 2 1

滿溢性尿失禁 8 17 16 11 2 20 0 2排尿困難 13 21 12 16 4 16 0 10頻尿急尿 2 24 4 9 0 17 0 5正常排尿 8 32 5 7 7 21 1 3總　　計 122 149 165 72 61 104 5 26


Analysis of UTI in 704 chronic SCIAnalysis of UTI in 704 chronic SCI

頸髓脊髓損傷胸髓脊髓損傷腰髓脊髓損傷薦髓及以下脊髓損傷總計


從來沒有 UTI 31 56 32 21 19 41 4 5209

(29.7%)

<1 / year UTI 45 46 66 19 17 22 0 3218

(31%)

≧ 1 / year UTI 38 15 57 12 14 14 1 4155

(22%)

不知道8 32 10 18 11 24 0 3

122

(17.3%)


Late complications in 704 SCILate complications in 704 SCI

頸髓脊髓損傷胸髓脊髓損傷腰髓脊髓損傷薦髓及以下脊髓損傷總計


完全沒有 44 60 43 16 18 44 3 3231

(32.8%)

反覆尿路感染 51 37 78 24 27 22 0 4243

(34.5%)

尿路結石 11 10 38 15 10 5 0 190

(12.8%)

腎臟水腫 16 6 21 5 2 8 0 462

(8.8%)

輸尿管逆流 14 7 19 6 8 0 0 155

(7.8%)

腎衰竭 6 5 8 2 2 1 1 025

(3.6%)


Management of voiding in 704 SCI in TaiwanManagement of voiding in 704 SCI in Taiwan

頸髓脊髓損傷胸髓脊髓損傷腰髓脊髓損傷薦髓及以下脊髓損傷


尿道留置導尿 23 10 14 7 7 4 2 -

膀胱造廔 13 5 16 1 2 1 - -

腹壓排尿 14 17 39 19 17 28 - 11

敲擊腹部 17 29 24 12 4 10 - 4

自行反射 39 27 55 13 21 11 3 4

間歇導尿 3 1 10 6 4 7 - 1

正常感覺 11 57 7 12 6 40 - 6

其　他 2 3 - 2 - 3 - -

總　計 122 149 165 72 61 104 5 26


The relationship of UTI frequency and SCI level and voiding management

The relationship of UTI frequency and SCI level and voiding management

r UTI Fequency

0/year 1/year 2/year 3/year sepsis

Level of SCI

Cervical SCI 41(34.7%) 20 (16.9%)

15 (12.7%) 42 (35.6%) 7

Thoracic or lumbar SCI 17 (18.3%) 21 (22..6%)

17 (18.3%) 38 (40.9%) 4

Sacral or infrasacral SCI 2 (5%) 9 (22.5%) 7 (17.5%) 22 (55%)

Complete lesion 15 30 28 51 9

Incomplete lesion 45 20 11 51 2

Initial management

Urethral Foley catheter 12 11 10 16 6

Suprapubic cystostomy 3 6 14 16 1

Crede maneuver 13 16 4 65 4

Abdominal tapping,reflex 7 5 - 1

CISC 11 - - 3

Normal 14 12 11 1

CISC=Clean intermittent self-catheterization.


Considerations in management of LUTD in chronic SCI

Considerations in management of LUTD in chronic SCI

Correct complications Treat hydronephrosis, treat UTI, treat vesicourete

ral reflux Improve quality of life Treat incontinence, convenience of bladder empt

ying, free of catheter,free of medicationIndividual treatment strategy for each SCI patient


Medical Treatment for LUTD in chronic SCIMedical Treatment for LUTD in chronic SCI To reduce detrusor hyperreflexia – anticholinergi

cs (oxybutynin,imipramine) To reduce bladder neck hyperreflexia – alpha-bl

ocker (tamsulosin, terazosin, prazosin) To reduce striated sphincter spasticity – skeletal

muscle relaxant (baclofen, diazepam) To increase detrusor muscle tone – cholinergic a

gent (urecholine)


Combination of medication for LUTS in Chronic SCICombination of medication for LUTS in Chronic SCI

To treat incontinence – anticholinergics and adrenergic agnist (methylephedrine) – CISC is needed, residual urine, UTI should be monitored

To facilitate voiding – cholinergic agent and alpha-blocker and skeletal muscle relaxant – incontinence exacerbates, upper tract deterioration if detrusor LPP is high


Side effects of Medical Treatment in chronic SCISide effects of Medical Treatment in chronic SCI

Constipation -- anticholinergics Hypotension –alpha-blocker Nasal congestion –adrenergic agonist General weakness – skeletal muscle relaxant Side effects increase as combination of medicati

on Cost benefit should be considered


Intravesical therapy for SCIIntravesical therapy for SCI Detrusor hyperreflexia – oxybutynin, capsaicin, r

esiniferatoxin, botulinum injection Reversible response Periodic instillation or injection


Capsaicin and resiniferatoxinCapsaicin and resiniferatoxin Intravesical agents for overactive bladder have been

mostly been used in neurogenic bladder disorders Capsaicin and resiniferatoxin have been successfull

y used intravesically to reduce urinary incontinence in neurogenic detrusor hyperreflexia

Resiniferatoxin has less acute side effect and similar efficacy as capsaicin

Resiniferatoxin is effective in treating detrusor hyperreflexia refractory to capsaicin treatment


Therapeutic effects of resiniferatoxinTherapeutic effects of resiniferatoxin 10 -5 to 10 -7 M RTX is effective for DH of SCI 10 -8 M RTX can significantly improve voiding

pattern and pain score in hypersensitive disorders and bladder pain

RTX is safe for application in humans Is RTX effective for DESD through inhibition of

DH in SCI patients？


Successful Therapeutic EffectsSuccessful Therapeutic Effects

Patient became dry Increase in 50% of maximal cystometric capacity Subjective improvement rate by >50% in incontin

ence or dysuria Significant change in quality of life in urination su

bjectively


Side Effects of RTX TreatmentSide Effects of RTX Treatment

Autonomic responses Elevated blood pressure Headache Bradycardia General malaise RTX was drained out and bladder irrigation was

performed if systolic BP >200mmHg


Results of resiniferatoxin therapyResults of resiniferatoxin therapy 20 patients (7 women and 13 men) Mean age 42.2 ±13.2 (24 – 66) years 10 cervical, 10 thoracic SC lesion 18 traumatic SCI, 2 multiple sclerosis All had DESD, 9 had autonomic dysreflexia 18 incontinence, 13 dysuria, 8 recurrent UTI


Responses of RTX instillationResponses of RTX instillation Initial excitatory response at 1-5 min Four types of initial responses Type 1: A sustained high pressure followed by c

omplete detrusor non-contraction Type 2: A high pressure contraction followed by progressively lower amplitude contractions Type 3: Intermittent high pressure contractions Type 4: Intermittent low pressure contractions


Initial CMG Tracing after RTXInitial CMG Tracing after RTX


Therapeutic Results of RTXTherapeutic Results of RTX 4/20 became dry during the daytime but incontin

ent at night time 8/20 had increased in frequency interval and voi

ded volume 8/20 had no significant improvement 8/13 with dysuria had improvement in spontaneo

us voiding (5) or on Crede maneuver (3)


Urodynamic Changes after RTXUrodynamic Changes after RTX

Baseline Post-RTX StastisticsCystometric capacity(ml) 102.1±31.5 236.6±88.6 P<0.001

Bladder compliance

(ml/cmH2O)23.7±12.1 25.9±15.3 P>0.05

Voiding pressure

(Pdet, cmH2O)55.9±23.2 47.5±28.1 P>0.05

Presence of

DESD100% 100%


Side Effects and QOL after RTXSide Effects and QOL after RTX Dizziness and headache with high BP and brady

cardia (4/20) Initial gross hematuria (5/20) Bladder irritation and frequency in all patients 7/20 responded that quality o life improved after

RTX 13/20 did not notice any significant change in Q

OL although objective data showed improved


Correlation of RTX Responses with Therapeutic Results

Correlation of RTX Responses with Therapeutic Results

A good response was noted in 12 patients Type 1: 5 (100%) Type 2: 4 (80%) Type 3: 2 (40%) Type 4: 1 (25%) Duration of RTX responses: 1 (6m), 6 (3m), 3

(2m), 2 (1m), repeat instillation in 7/12


Urodynamic tracings before, during and after resiniferatoxin

Urodynamic tracings before, during and after resiniferatoxin


Botulinum toxin injectionBotulinum toxin injection Botlinum toxin has been used to inject striated ur

ethral sphincter for grade 3 DESD Refractory detrusor hyperreflexia can be eradica

ted by intra-detrusor injection of botox Reversible effect and possibilty of antibody form

ation after repeated injection Cost-benefit should be weighed


Reduction of Voiding pressure after Botulinum toxin in DAReduction of Voiding pressure after Botulinum toxin in DA


Rhythmic detrusor contractions in SCI with DESD after Botox

Rhythmic detrusor contractions in SCI with DESD after Botox


Botulinum A Toxin Detrusor Injection for Detrusor HyperreflexiaBotulinum A Toxin Detrusor Injection for Detrusor Hyperreflexia 5 IU/Kg Botox (Botulinum A toxin) was injected t

o 30 sites into detrusor muscle Decreased detrusor pressure and increased cyst

ometric capacity after Botox Increased residual urine and CISC is needed Abdominal tapping to void Indicated in refractory detrusor hyperreflexia


Botulinum A toxin 250 U Detrusor Injection for Detrusor Hyperreflexia

Botulinum A toxin 250 U Detrusor Injection for Detrusor Hyperreflexia


Cauda equina lesion andDetrusor areflexiaCauda equina lesion andDetrusor areflexia


Grade 1 DESD in a SCI WomenGrade 1 DESD in a SCI Women


Grade 1 DESD in Cervical SCIGrade 1 DESD in Cervical SCI


Failure of Pharmacological MxFailure of Pharmacological Mx Presence of vesicoureteral reflux Severe bladder fibrosis and trabeculation Presence of severe bladder outlet obstruction Severe outlet incompetence Azotemia or renal failure No improvement in quality of life


Surgical treatment for complications of chronic SCI

Surgical treatment for complications of chronic SCI

External sphincterotomy and urethral stent Augmentation cystoplasty Bladder autoaugmentation Continent urinary reservoir formation (Kock pouch) Pubovaginal sling procedure Continent cystostomy Ureteral reimplantation


External SphincterotomyExternal Sphincterotomy Indicated in quadriplegic patients with DESD Potentially not result in total incontinence Urinary tract infection can be eliminated Free of catheterization Re-do is possible in 25% patients with inadequat

e sphincter relaxation or scarring 25- 30 % may have persistent hydronephrosis


Technique of SphincterotomyTechnique of Sphincterotomy 12 o’clock position Incision from BN to bulbous Cutting deep to fat & vessel Bleeding can be controlled Avoid diffused coagulation On Foley catheter for 2 days


Intravesical pressure after external sphincterotomy

Intravesical pressure after external sphincterotomy


Reduction in MUCP afterExternal sphincterotomyReduction in MUCP afterExternal sphincterotomy


Urethral StentUrethral Stent Indwelling a distensible urethral stent for scarred

membranous or severe DESD refractory to sphincterotomy

Complication should be weighed: stone formation, stent erosion, persistent UTI, total incontinence

Only 2/11 longer follow-up patients needed to be removed


Implantation of a urethral stentImplantation of a urethral stent


Augmentation cystoplastyAugmentation cystoplasty A bladder capacity of less than 250ml Overflow incontinence and large residual urine Presence of hydronephrosis Azotemia and frequent pyelonephritis Patient is able to catheterize by himself Side effect or refractory to pharmacological thera

py


Technique of augmentation cystoplastyTechnique of augmentation cystoplasty


Surgical results after augmentation cystoplastySurgical results after augmentation cystoplasty


Bladder autoaugmentationBladder autoaugmentation Partial myomectomy of bladder wall Increase bladder compliance and capacity by dis

tensible bladder mucosa Less surgical morbidity and complication Secondary fibrosis and reduced capacity after lo

ng-term follow-up Serve as first line surgical procedure for SCI


Bladder autoaugmenttionBladder autoaugmenttion


Ureteral reimplantationUreteral reimplantation Not suitable in trabeculated bladder High failure rate after ureteral reimplantation or c

ollagen injection Contraindicated in SCI patients with DESD & AD Combined augmentation and anti-reflux procedu

re is a better way


Anti-reflux afferent nipple valveAnti-reflux afferent nipple valve


Continent Reservoir (Kock pouch)Continent Reservoir (Kock pouch) Creation of a continent reservoir by a 40-cm seg

ment of ileum Detubularization and double folded ileum can ha

ve a volume of 600ml Anti-reflux and anti-incontinence nipple valves Self-catheterization is needed Suitable for female SCI with good hand function


Sonography of Kock pouchSonography of Kock pouch


Degeneration of intestinal wall in Urinary reservoirDegeneration of intestinal wall in Urinary reservoir


Transurethral injectionTransurethral injection Transurethral injection of botulinum toxin may re

duce sphincteric tone and facilitate voiding in SCI with DESD or detrusor areflexia

Transurethral injection of collagen or Teflon paste may bulk sphincter and increase urethral tone, eliminate incontinence in lower level SCI

Other new devices implant into bladder neck or sphincteric urethra to combat incontinence


Artificial Urethral SphincterArtificial Urethral Sphincter


Artificial Urethral Sphincter Artificial Urethral Sphincter 95% in the NVD patients (half of 250) receiving

AUS implantation became continent, 78% at the first AUS attempt

Revision rate in neurogenic voiding dysfunction is 33%

Annual incidence of erosion was 5% Overall success rate was 77%,revision rate 59%

in 107 children

Documents

排尿障礙治療中心 版權所有 Spinal cord injury Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital Hualien

排尿障礙治療中心版權所有 Spinal cord injury Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital Hualien