Urodynamics in Neuro-Urology

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1 Urodynamics in Neuro-Urology R Hamid MD (Res), FRCS (Urol) Consultant Urologist London Spinal Injuries Unit, Stanmore & University College London Hospitals

2 Micturition Micturition can be visualized as a process in which neural circuits in the brain and spinal cord coordinate the activity of smooth muscle in the bladder and urethra These circuits act as on-off switches to alternate the lower urinary tract between 2 modes of operation: storage and elimination.

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4 History A detailed history of onset and duration of symptoms is required The storage and voiding dysfunction are separately documented Special attention is required for evaluation of urinary incontinence Neurologic symptoms with duration and treatment is considered with attention to mental status, mobility and hand function It is helpful to assess for family support Particular attention is given to evaluate possible red flags including recurrent infections, pain and haematuria It is not uncommon to ignore the bowel and sexual function whilst taking urological history

5 Physical Examination Assess mobility and hand function Urologic examination: bladder emptying, external genitalia and rectal Focused neurologic evaluation- Reflexes & sensations in the genital area The dermatomes and reflexes are evaluated The S2-S4 reflex arc can be elicited Bulbo-cavernosus reflex

6 Spinal Shock Period of excitability at & below SCI Absent somatic reflexes & flaccid muscle paralysis Autonomic activity Acontractile, areflexic bladder Sphincter = residual tone retention (catheter / SPC / CISC) Lasts days to months

7 Bladder Recovery Last to recover Majority of recovery in 1st 6 months More subtle changes up to 2-5 years? Reflex recovery 1st = striated muscle of pelvic floor Return of Bulbocavernosus reflex S3,4: pinch glans/clitoris or pull catheter and anal sphincter contracts on your finger If BCR present: sacral micturition centre = intact

8 Urodynamic Principles Urodynamics room Video-Urodynamics Urodynamics question Patient position 8

9 Urodynamic Principles Filling rate Residual volume? Antibiotics Autonomic Dysreflexia 9

10 The symptoms are flushing of skin above level of injury, hypertension with reflex bradycardia and headache Autonomic dysreflexia This is a true life threatening emergency It can occur in patients with a SCI above T6 The most common stimulus is from bladder Faecal loading and skin or urine infections There is a massive sympathetic discharge secondary to a specific stimulus

11 Autonomic dysreflexia Most crucial step in management Recognition Offending stimulus should be removedis removed This is generally emptying of the bladder The patient is sat up Nifedipine 10 mgs is given as bite / chew and not as a sublingual The blood pressure is measured

12 Spinal Cord Injury (SCI) / Iatrogenic This can further be divided into 3 groups If the lesion is above T10 then the patient most likely has an UMN type injury with NDO & DSD If the injury is below L2 the likely presentation is a LMN type injury with hypocontractile / atonic bladder The injuries between vertebral levels T10 L2 are generally mixed type and present with a combination of above symptoms.

13 Surpapontine Lesions CVA /Brain injury/cerebral palsy Degeneration Parkinson s/msa/alzheimer s Demyelination Multiple Sclerosis Frequency & urgency (NDO) Co-ordinated detrusor and sphincter function

14 Traumatic SCI Demyelination MS / TM Vascular AVM Spinal Surgery Suprasacral Lesions NDO Poor emptying DSD Dangerous bladder

15 Infrasacral Lesions Spina bifida Intervertebral disc Pelvic surgery Diabetes mellitus Flaccid paralysis with sensory loss Absent conus reflexes Detrusor areflexia Possible reduced compliance Sphincter weakness

16 Suprasacral infrapontine injury Neurogenic Detrusor Overactivity Detrusor sphincter dyssynergia No sensation VCMG findings Loss of bladder sensations NDO DSD Loss of compliance Reflux Trabeculated bladder

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21 VCMG demonstrating poor bladder compliance

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23 Acontractile Detrusor Acontractile Sphincter No sensation VCMG findings Infrasacral injury No sensations No loss of compliance No NDO No reflux Large capacity bladder Stress incontinence No voluntary detrusor contraction Strain voiding

24 Summary Neurological history Urodynamic question Patient factors Management of potential complications 24

25 Thank you