Microsoft PowerPoint - Neurourology Expert course 2019.pptx1
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3 …and additional subtleties…
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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….
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Basic neurological examination
• Walking, or wheelchair (speed to toilet,  ability to transfer). 
• Contractures, Hand function  • Palpable bladder; post void residual • Pelvic examination; 
– Pelvic floor support bladder, POP, anal – Sensation – Reflexes 
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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
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 co
ordinate 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, decisionmaking
Nervous control of LUT
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 coordination/ 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  perinatal lesions
Suprasacral cord  Spastic paraparesis Trauma MS
Sacral spinal cord Sacral agenesis Conus injury Tumour
Subsacral Spinal dysraphism Pelvic nerve injury  Neuropathy
No maturation of normal function
Predictable loss of function
Evolving loss of function
Classification Condition Early neurological features Epidemiology Similar conditions Demyelinating disorders
MS Unilateral painful loss of vision, parasthesias, motor deficit. ED in 53% of males.
Peak age of onset: 3040 years.
Transverse myelitis
Neuromyelitis optica
Parkinsonian syndromes
MSA Postural hypotension and incoordination. Slow movement, slurred speech, poor balance and syncope. 83% ED at diagnosis
Mean onset 54. 4.4/100000, slightly more in males.
Idiopathic Parkinson’s Unilateral 2Hz tremor Progressive supranuclear palsy
Vascular Parkinsonism Miscellaneous intracranial disorders
NPH Bradykinetic broad based gait, urinary incontinence and dementia.
Typical >60. Slightly more common in males. 22/100,000.
Brain tumours
Strokes
Spinal Dysraphism Spina bifida occulta, often asymptomatic. Dimple or tuft of hair on the back. If tethered cord is present, possible impaired lower limb or bowel function.
Congenital, may affect up to 20% in North America.
Cauda equina syndrome
Orthostatic hypotension. Dry mouth, anhidrosis, sicca syndrome, pupillary dysfunction, gastroparesis, constipation
Adults of all ages. Females more likely. Rare. Can be rapidly progressive or subacute.
Pure autonomic failure
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• Progressively worsening stream, with post  void residual. Rx Bladder neck incision. 
• Went in to acute retention, 800mls  • 1 year later botox.  • Was not taught ISC until 6 months later.  500mls capacity, 300ml by ISC. 
• Poor flow, using pads for worsening leaks.  Nocturia 58x, sometimes enuresis.
• Referred to local hospital; urodynamics, flexi  cystoscopy TURP. 
• Symptoms are worse. Now sore with some  resistance to ISC and getting bleeding
• MRI; normal (requested by urologist).  • Awaiting neurology review; no unexplained  symptoms (diplopia, headaches, loss of  vision), but does get dizzy in the evening explains this by sleep deprivation. 
• Erectile dysfunction since 2011 difficulty  gaining and sustaining erection. Viagra. 
• O/e inc BMI, poor gait, 
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• Pressure profile; low sphincter pressure  and very weak voluntary squeeze.
• Filling; clear and even prostate resection  cavity. No vesicoureteric reflux. Pelvic floor  descent with cough/ strain. 
• Bladder compliance only 4 mls/ cm H2O;  (120ml, 30 cm H2O) 
• Leakage (low pressure, 33 cm H2O).  • Increased filling sensation, leading to low  cystometic capacity. 
• Unable to pass urine straining only.  • Emptied by ISC, 230ml. 
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• High likelihood of neurological basis due to  severity of onset, broad spectrum and  associated erectile dysfunction. Weak  sphincter and poorly compliant bladder. 
• Neurology consultation requested.  • Likely to need assessment of brainstem. 
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• Parkinson’s disease • Normal pressure hydrocephalus • Multiple system atrophy • MS • Spinal conditions • Early dementia
29Wei & Drake. Curr Opin Urol 2016; 26: 11-16
The top line
• LUTS which seem a bit severe and sudden – Something seems odd – Loss of filling sensation/ flow sensation
• Screening questions: erectile/ ejaculatory,  transient blindness, numbness, dizziness
• Speech, walking, tremor, pelvic exam • Initiate formal neurological assessment (do  not request MRI yourself). 
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5th ICI Neurological Incontinence
Cases
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40 year old female; What is abnormal about the  detrusor contraction?
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32 female; Arnold Chiari (cerebellar herniation, no hydro- cephalus). UDS = reduced filling sensation, voids by pelvic floor relaxation. If she later gets SUI, would you do midurethral tape?
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risk)
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Detrusor sphincter dyssynergia • When there is flow, detrusor pressure drops
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