Morbidity of dysfunctional voiding syndrome.

OBJECTIVES: External sphincter dyssynergia in the absence of an identifiable causative neurologic lesion (dysfunctional voiding, Hinman-Allen syndrome, non-neurogenic neurogenic bladder) has been known to cause significant morbidity. To determine the outcomes in this syndrome, we conducted a retrospective study of 37 patients referred for urodynamic studies and subsequently diagnosed with dysfunctional voiding. METHODS: After diagnosis, follow-up was conducted through chart review and telephone calls to the primary physicians or the patients. RESULTS: Follow-up was possible in 27 patients (17 female, 10 male; mean follow-up 49 months, range 4 to 192). The average age at diagnosis was 12 years. Eleven patients developed significant or ongoing morbidity. Ten of these 11 patients underwent 17 operations. Eight patients were cured through medication, behavioral modification, intermittent catheterization, and/or other nonoperative treatments. The remaining 8 patients did not experience significant morbidity but did not have resolution of their symptoms as of their last medical evaluation, and most were lost to follow-up. CONCLUSIONS: Dysfunctional voiding resulted in severe morbidity in 11 (40%) of 27 study patients. Eight patients (30%) were cured using nonoperative, conservative treatments, and 8 (30%) had unresolved symptoms within the follow-up period. Urodynamic studies are essential in the diagnosis of the syndrome but cannot be used to consistently predict outcome.

Lower urinary tract dysfunction in multiple sclerosis.

Previous investigators have shown that in multiple sclerosis failure to empty the bladder was secondary to detrusor-distal sphincter dyssynergia or areflexia. However, our urodynamic evaluation of 46 female and 43 male patients with multiple sclerosis revealed that 63 percent of patients failed to empty their bladders because of a hypocontractile detrusor, and only 6 percent had areflexia. Detrusor-distal sphincter dyssynergia (6%) and bladder neck obstruction (6%) were present in only 12 percent of patients. Hyperreflexia was common (78%) and was associated with hypocontractility in 63 percent of patients. Urgency incontinence was significantly more common in females and voiding difficulty significantly more common in males. Sensation was also reduced in 74 percent of female and 77 percent of male patients. In conclusion, failure to empty the bladder in multiple sclerosis is most commonly associated with hypocontractility, and the combination of hyperreflexia and hypocontractility produces the symptoms of urgency and incomplete emptying.

Catheter modification for transrenal temporary total ureteral obstruction: the "occlusive" nephroureteral catheter.

When temporary diversion of urine is desired and a simple nephrostomy catheter is insufficient or passage of a ureteral stent cannot be achieved, a standard 8 or 10 F nephroureteral catheter can be modified to provide a single nephrostomy drainage catheter with an occluded ureteral segment that provides total diversion of urine. The "occlusive" nephroureteral catheter is exchangeable over a guide wire as necessary. When healing of the ureteral or bladder process has occurred, the catheter is removable, allowing restoration of normal urine flow.

Fate of upper urinary tracts in patients with indwelling catheters after spinal cord injury.

Several modes of urinary tract drainage exist for the spinal cord-injured (SCI) patient, but the use of an indwelling catheter is discouraged. We retrospectively reviewed the charts of our traumatic SCI patients followed twenty years or more since initial injury to compare urinary tract preservation and the incidence of urologic complications in patients with neurogenic bladders voiding spontaneously with those using long-term indwelling catheters. Eighty-one patients with long-term injuries were identified; 73 of them fit the study criteria. Forty-one patients voided spontaneously having a balanced bladder or performing intermittent catheterization or have undergone sphincterotomy or vesicostomy, and 32 had indwelling suprapubic or Foley catheters. Renal function measured by creatinine clearance was similar in both groups: 81.3 +/- 20.2 mL/min for spontaneous voiders and 83.7 +/- 24.9 mL/min for catheterized patients. Review of urinary tract imaging and incidence of complications in both groups was very comparable, with the exception that the catheterized group had a higher prevalence of scarring and calicectasis on radiologic imaging of the upper urinary tracts which was statistically significant. Of the remaining population, in 6 of 81 patients, bladder cancer developed, and they underwent radical cystectomy and urinary diversion and 2 had proximal diversion alone. Of the 6 patients with bladder cancer, 2 were spontaneous voiders with transitional cell carcinoma (TCC) developing. Three of the 6 patients had indwelling catheters: in 1 patient TCC developed, in 1 adenocarcinoma, and in 1 squamous cell carcinoma. In 1 patient TCC developed in a defunctionalized bladder after ileal conduit formation. Based on this study, we can conclude that in select groups of SCI patients, the choice of an indwelling catheter may be made if other methods fail, provided patients undergo regular upper urinary tract imaging and cystoscopy.

Few patients with "chronic prostatitis" have significant bladder outlet obstruction.

OBJECTIVES: A high prevalence of significant bladder outlet obstruction has been reported among men diagnosed as having "chronic prostatitis." To evaluate the possibility that case selection may determine this high prevalence, we compared findings in patients referred directly to our Urodynamic Unit with that of patients evaluated in our Prostatitis Clinic. METHODS: The videourodynamics records of 201 men aged 18 to 50 years who presented to the Urodynamic Unit with any lower tract symptoms (irritative and/or obstructive with or without pain) were compared with the findings in 123 Prostatitis Clinic patients. The latter were evaluated for obstruction with flow rates and, if abnormal, by retrograde urethrograms and videourodynamics. RESULTS: Only 37 (18%) of 201 patients referred to the Urodynamic Unit had pain as a significant symptom and might have been diagnosed as having chronic prostatitis. Of these 37 patients, 4 (11%) had definite obstruction, 6 (16%) were equivocal, 6 (16%) were hypocontractile, 1 (3%) had pseudodyssynergia, and 7 (19%) had normal findings. The remainder had abnormalities of bladder filling (hypersensitivity in 11 [30%] and detrusor instability in 2 [5%]). Fewer of the 123 patients with prostatitis had obstruction (definite in 2 [1.6%] and equivocal in 1 [0.8%]) (P = 0.03), 2 (1.6%) had hypocontractile detrusors, and 2 had urethral strictures. CONCLUSIONS: Patients referred to the Urodynamic Unit with lower urinary tract symptoms and pain rarely have bladder outlet obstruction. However, they are significantly more likely to have bladder outlet obstruction than patients referred to the Prostatitis Clinic who can be screened for obstruction by history, flow rate, postvoid residual, and retrograde urethrogram.

The value of sphincter electromyography in urodynamics.

Multichannel urodynamic evaluation combined with sphincter electromyography was done on 102 patients. Normal and abnormal activity was defined. When detrusor hyperreflexia occurred in patients with obstruction, idiopathic detrusor hyperreflexia and upper motor neuron disease there was a reflex relaxation of the pelvic floor in 52 per cent of the cases. Electromyographic evidence of dyssynergia was associated with other evidence of sphincter obstruction in 50 per cent of the patients who voided by detrusor contraction and in 9 per cent of the patients who voided by Valsalva's maneuver. A diagnosis of dyssynergia should not be made from the electromyographic evidence alone, especially if the patient strains to void.

Lower urinary tract dysfunction in cerebral palsy.

The urodynamic findings in 33 patients with cerebral palsy referred with lower urinary tract symptoms were reviewed. Difficulty urinating was the predominant symptom in approximately half of the patients and half of these also had hyperreflexia and urgency when full. Three patients had varying degrees of retention and the remaining 14 had difficulty initiating a urinary stream. The other half had urgency incontinence as a major presenting symptom and this was associated in nearly all cases with hyperreflexia. There were 10 adults: 5 with difficulty urinating and 5 with urgency. The more serious manifestations, such as retention, were found only in the adults, suggesting that difficulty urinating may progress in adult life. Classical detrusor-sphincter dyssynergia with bladder wall changes was seen only once, and the cause of difficulty urinating in the other patients seemed to be due to a lack of voluntary control over and the hypertonus of the pelvic floor.

Detrusor hyperreflexia: the effect of posture and pelvic floor activity.

Detrusor hyperreflexia is described in patients with neurological disorders, bladder outflow obstruction, persistent enuresis and in female incontinent patients with obvious neurological or urological disease. Postural changes were present in 60% of the patients and in 45% of the patients examined reflex relaxation of the pelvic floor occurred with the uninhibited detrusor contractions.

Clinical experience with upper tract urodynamics.

Of 25 upper tract urodynamic studies performed in 22 patients 9 positive results were obtained. The diagnosis of intrinsic ureterovesical junction obstruction was suspected in 11 children but only confirmed in 2. However, in 6 other children changes in bladder volume markedly affected upper tract function. While diuretic renography may confirm obstruction in many doubtful cases, when function is poor and the system is dilated massively a urodynamic study often will be the only definitive diagnostic procedure.

Bacteriuria with fever after spinal cord injury.

Urinary tract infection continues to be a common problem among spinal cord injured (SCI) individuals despite the strides that have been made during the last decade in the care of the neurogenic bladder. A critical analysis of the system of drainage compared with the occurrence of bacteriuria with fever (BWF) is reported in a group of 705 SCI patients. At the first year (year 1) follow-up, patients being catheterized by someone else (ICO) were much more likely to have experienced at least one episode of BWF than those on self-intermittent catheterization (SIC) (p less than 0.025) or those using an indwelling catheter (IND) (p less than 0.005). In patients who underwent external sphincterotomy, the incidence of BWF was significantly decreased in year 1 (p less than 0.025) compared to those on ICO.

Ileocecal bladder augmentation in myelodysplasia.

We discuss 14 children and adolescents with myelodysplasia who underwent bladder augmentation with the ileocecal segment. The bowel was not detubularized nor was the ileocecal valve intussuscepted. Urodynamic evaluation was performed before and after the procedure in 13 patients with a followup of 1 to 8 years. Postoperative capacity and compliance were normal but cecal contractions occurred in 8 patients despite adequate doses of anticholinergics. Reflux was demonstrated at capacity with a cecal contraction in 4 patients but upper tract dilatation and infection were not clinical problems. Three patients required reoperation for complications owing to ureteroileal stenosis and/or urinary tract calculi. Although the clinical results were satisfactory, detubularized segments of bowel with intussuscepted afferent loop valves to prevent reflux may resolve these problems in the future.

External urethral sphincterotomy: long-term follow-up.

UNLABELLED: We retrospectively reviewed the charts of 37 male spinal cord injury patients who underwent sphincterotomy from 1986-1993 to evaluate the long-term results of this procedure. Patients were selected for the operation based on urodynamic criteria and all had some detrusor activity or were able to void by Valsalva's maneuver. There were 26 cervical injuries and 11 thoracic injuries. The operation was judged a failure if the following were present postoperatively: the presence of large post void residual volumes associated with urinary tract infections, autonomic dysreflexia symptoms associated with bladder overdistension or high voiding pressures, and/or progressive upper tract deterioration due to persistent vesicoureteral reflux or poor bladder emptying. Eighteen' operations were failures and 19 operations were successful. Causes for sphincterotomy failure included recurrent detrusor sphincter dyssynergy (6), detrusor hypocontractility (6), bladder neck contracture (3), stricture at the external sphincter (1), incomplete sphincterotomy (1), and unknown etiology (1). The reoperation rate was 32%. The mean follow-up time was 49 months for the failure group (range 2-81) and 26 months (range 2-54) for the successes. The longer mean follow-up period in the former group suggests that the number of failures increased with time. There was no predictor of failure among any of the following parameters: age at operation, level of injury, previous bladder neck/sphincter operations, preoperative maximum detrusor contraction pressures, or rise time to maximum pressure. IN CONCLUSION: (1) the external urethral sphincterotomy, even in appropriately selected patients, can have a high failure rate over time, and (2) we could not identify any variables to predict an unsuccessful operation using our present selection criteria.

Urodynamic assessment of incontinence after prostatectomy.

There were 15 men with incontinence after prostatectomy who were assessed with a urethral pressure profile and a multichannel filling and voiding study with sphincter electromyography. Of these 15 patients 7 had sphincter weakness alone, 7 had sphincter weakness and detrusor hyperreflexia, and 1 had detrusor hyperreflexia alone. Full urodynamic assessment is essential before treatment can be recommended for incontinence after prostatectomy.

The effect of bladder function on the dynamics of the ureterovesical junction.

Upper tract perfusion studies in suspected ureterovesical junction obstruction should always be performed with measurement of intravesical pressure and with variation in bladder volume. Obstruction observed with increasing bladder volumes may be related to a non-compliant bladder wall, mechanical obstruction at or near the junction itself or a combination of both factors.

Increased residual urine in patients with bladder neuropathy secondary to suprasacral spinal cord lesions.

Multichannel urodynamic studies were done on 30 patients with incomplete bladder emptying secondary to suprasacral spinal cord lesions. In 11 patients fluoroscopy was done simultaneously. A single most important factor accounting for the increased residual urine was present in 21 cases: inadequate detrusor contraction in 10, sphincter dyssynergia in 6 and bladder neck obstruction in 5. A combination of 2 of these factors was present in 3 patients. Although the initial residual urine volume was high in 6 patients voiding during the urodynamic study was efficient and no residual urine was demonstrated at that time. Urethral pressure profiles were variable, depending on whether a spastic external sphincter contraction was present during the procedure. It is concluded that bladder pressure and sphincter electromyographic measurement during voiding, combined with fluoroscopy, are ideal methods to identify the factors responsible for incomplete emptying in problem cases. The urethral pressure profile is of limited value in the initial assessment of these patients.

The effect of autonomic drugs on ureteric peristalsis: a canine in vivo study.

An in vivo canine model was developed in which the renal pelvis was perfused by a cannula nephrostomy and ureteric activity assessed by monitoring bolus volume and interperistaltic interval. The effect of autonomic drugs showed that the ureter contained alpha-adrenergic receptors which on stimulation caused an increase in ureteric contraction rate and a decrease in bolus volume. With beta-adrenergic receptor stimulation, there was complete inhibition of ureteric peristalsis for a variable period and evidence is presented that the beta-adrenergic receptors may be beta 1 rather than beta 2. Cholinergic stimulation of ureteric rate was observed, but seemed to be mediated indirectly via alpha-adrenergic receptors. No significant change was seen in ureteric activity with adrenergic blocking agents alone, suggesting that the physiological importance of these receptors in normal activity is questionable.

The effect of glucagon and diazoxide on the normal and obstructed upper urinary tract.

The effect of diazoxide and glucagon were studied on the freely draining upper urinary tract and after varying periods of obstruction in dogs. Without obstruction, diazoxide produced longer inactive periods than glucagon and recovery was associated with less retrograde activity. Following obstruction for 5--10 min, 6 and 24 h, diazoxide decreased renal pressure and the effect was greatest when the upper tract was obstructed for the shortest period. Glucagon also produced an overall reduction in pressure after 5--10 min and 6-hour periods of obstruction, but there was an initial rise in pressure after 5--10 min of obstruction. At 24 h there was an increase, but no overall decrease in pressure after glucagon. Diazoxide produced a greater fall in pressure after 5--10 min and 24 h of obstruction, and a faster fall in pressure after 5--10 min and 6 h of obstruction as compared to glucagon. Diazoxide may be a more effective therapeutic agent in the management of ureteral calculus disease than glucagon.

Management of ileal conduit stomal obstruction: a urodynamic study.

Urodynamic perfusion studies have shown that edema or incrustation and ulceration may produce stomal obstruction in patients with ileal conduits. High emptying pressures may be present before there is any increase in the residual or conduit capacity, or before upper tract deterioration has occurred. Nine patients with early stomal obstruction were treated medically with acidification of the urine in the collecting bag and were compared to 6 patients who had stomal obstruction owing to irreversible changes and who were treated by surgical revision. In both groups emptying pressure returned to normal after treatment.

Urodynamic studies in children who wet.

The value of urodynamic evaluation was assessed in children with diurnal and/or nocturnal enuresis without overt obstruction or neuropathy. The hypothesis that children with bladder instability and dysfunctional voiding represent 2 separate populations was also examined. A simplified urodynamic method was used to evaluate 191 children and they were divided into 3 groups: 64 had normal bladders which were stable during filling and voiding was co-ordinated and complete; 97 had unstable bladders but voiding was normal and co-ordinated; 30 had dyssynergic voiding and an increased volume of residual urine. The urodynamic evaluations were helpful in distinguishing the large number of children with normal findings in whom the problem was motivational. The children with unstable bladders had a physiological abnormality due to delayed maturation and in these cases anticholinergic and musculotrophic agents were usually helpful. The dysfunctional voiders had serious behavioural problems, were difficult to treat, and often required a multidisciplinary approach. These data indicate that there are indeed 2 distinct groups: 1 with instability alone and 1 with dysfunctional voiding with or without instability. Although infection and/or reflux are common in the former, the more devastating urinary tract changes, particularly heavy trabeculation and elongation of the bladder, occur in the latter group.

Reduction in human bladder wall compliance following decentralization.

The urodynamic records of patients who presented with voiding symptoms and/or incontinence, and who had areflexia after conal-cauda equina injury (33) or a radical pelvic operation (31) were examined. In contrast to reported experimental and clinical evidence, we found a higher prevalence of decreased compliance in the patients who had undergone a radical pelvic operation than in those who had sustained conal-cauda equina injury.