Sensory Disorders of the Bladder and Urethra
Autonomic involvement occurs early in both inherited familial amyloid polyneuropathy and when amyloidosis is secondary to myeloma or benign plasma cell dyscrasia. Typically there are features of somatic sensory involvement such as loss of pain and temperature sensation in the feet when the disease has advanced to produce autonomic involvement. A study of the urogenital complaints of 12 patients with Spanish familial amyloid polyneuropathy type I amyloidosis showed reduced bladder contractility and a reduced flow rate in most of them and two patients had a significant post-micturition residual volume Villaplana et al.
All were generally very unwell and undergoing liver transplantation and had evidence of severe generalized neuropathy. These are usually the patients with more severe neuropathy and the bladder symptoms appear after weakness is established. Both detrusor areflexia and bladder overactivity have been described Sakakibara et al. Painful urinary retention usually occurs in both cholinergic and pan dysautonomia Kirby et al. There is a recessively inherited type II congenital sensory neuropathy in which a sensory disturbance of bladder function has been described with preservation of voluntary micturition Bardosi et al.
The peripheral innervation of the pelvic organs can be damaged by extirpative visceral surgery such as resection of rectal carcinoma, radical prostatectomy or radical hysterectomy.
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The dissection necessary for rectal cancer is likely to damage the parasympathetic innervation to the bladder and genitalia as the pelvic nerves take a medio-lateral course through the pelvis either side of the rectum and the apex of the prostate. The nerves may either be removed together with the fascia which covers the lower rectum or may be damaged by a traction injury as the rectum is mobilized prior to excision Mundy, A prospective study of patients undergoing sphincter sparing surgery for low rectal carcinomas in which each patient acted as their own control, showed that post-operatively there was a significant increase in post-micturition residual urine volume.
Urinary incontinence following a radical prostatectomy or a radical hysterectomy, which includes the upper part of the vagina, is probably also due to damage to the parasympathetic innervation of the detrusor and, at least in the case of a radical prostatectomy, direct damage to the innervation of the striated urethral sphincter Yalla and Andriole, ; Leveckis et al. Although myotonic activity has not been found in the sphincter or pelvic floor of patients with myotonic dystrophy, bladder symptoms may be quite prominent Sakakibara et al.
Urinary retention or symptoms of obstructed voiding in young women in the absence of overt neurological disease have long puzzled urologists and neurologists alike and in the absence of any convincing organic cause the condition was often said to be hysterical. Typically the clinical history is of a young woman aged between 20 and 30 years who presents with retention and a bladder capacity in excess of 1 l.
The history is often that over the preceding 12 h she has found herself unable to void, and although by the time of presentation she may be highly uncomfortable, she does not have the sensations of extreme urgency that might be expected. There are no other clinical neurological features or laboratory investigations to support a diagnosis of multiple sclerosis, and MRI of the brain, spinal cord and cauda equina are normal. The lack of sacral anaesthesia makes the possibility of a cauda equina lesion improbable. Fowler and colleagues Fowler et al. The abnormal EMG activity is localized to the urethral sphincter and consists of a type of activity which would be expected to cause inappropriate contraction of the muscle.
Superficially it sounds like myotonia but detailed EMG analysis shows there are significant differences and the sphincter activity consists of two components, complex repetitive discharges CRDs and decelerating bursts Dyro et al. It is known from other electromyography studies that complex repetitive discharges are due to direct spread of electrical activity from one muscle fibre to another. CRDs have a characteristic sound over the audio output of the EMG machine and sound either like a motorcycle or helicopter.
The hypothesis that the activity impaired sphincter relaxation was confirmed recently in a study by Deindl and colleagues Deindl et al. Why this type of EMG activity should develop particularly in the urethral sphincter is not known. It is a type of activity which the striated urethral sphincter and to some extent the striated anal sphincter muscles are prone to develop, but is rarely encountered in skeletal striated muscle Jensen and Stien, It is possible that this relates in some way to the size of the muscle fibres of the sphincters which are known to be of relatively small diameter Gosling et al.
The disorder may possibly be the manifestation of a focal, hormonal dependent channelopathy. This would explain why the condition is seen only in pre-menopausal women. Whatever the exact cause or nature of the EMG abnormality, it is the commonest finding on concentric needle EMG of the striated muscle of the urethral sphincter in young women with retention.
The clinical picture of a woman with this primary sphincter abnormality, however, depends on the reaction of her detrusor muscle to relative outflow obstruction and the same EMG finding has been reported in women with obstructed voiding and detrusor instability Potenzoni et al. Others have reported finding this activity in the urethral sphincter Butler, ; Dibenedetto and Yalla, ; Dyro et al. Webb and colleagues Webb et al. The natural history of this disorder was investigated recently by means of a questionnaire sent out to women seen over the last 10 years.
The peak age incidence was 25 and retention could have been either of acute or chronic onset, chronic urinary retention being partial and somewhat more common in older women. The EMG abnormality described above is very rarely found in women over the age of 45 years and almost never in post-menopausal women.
Many of the women have had an interrupted urinary stream, but been unaware that this is abnormal, so that a voiding history can be quite misleading unless carefully taken. To the patients the difference between being in complete retention and able to pass some urine is tantamount and they may report recovery from former retention if they are able to pass any urine. Being unaware of the extent of their incomplete emptying, they may continue in partial retention with abnormal voiding for months or even years Swinn et al.
Unfortunately none of the women had themselves discovered an effective treatment and efforts to treat the condition by the hormonal manipulation, injections of botulinum toxin Fowler et al. However, the results of using the recently introduced sacral nerve stimulator are promising Vapnek and Schmidt, ; Elabbady et al. The mechanism of action of this therapeutic intervention is being actively researched.
Anticholinergic medication is currently the most effective treatment for detrusor hyperreflexia. Until the recent introduction of tolterodine, oxybutynin was most commonly used in the UK. This has a relatively selective effect on the parasympathetic innervation of the detrusor muscle but has a frequently complained of side-effect—a dry mouth. It is claimed that tolterodine has the same efficacy but causes less dry mouth. Where neither oxybutynin nor tolterodine is available, alternatives such as propantheline bromide or imipramine can be tried.
Desmopressin DDAVP spray is a nasal spray preparation of a synthetic antidiuretic hormone, first introduced to treat diabetes insipidus. Nowadays it is widely used by children with nocturnal enuresis but in the UK is also licensed for treatment of patients with multiple sclerosis and night-time frequency Hilton et al. One or two nasal puffs of DDAVP from a metered-dose spray Desmospray administered on retiring reduces urine output for the following 6—8 h, and an oral preparation of DDAVP Desmotabs is now available with the same effect.
Some patients with multiple sclerosis who were given Desmospray at night chose to use this during the day instead and a placebo controlled trial showed a significant reduction in voiding frequency in the 6 h following treatment and a strong patient preference for the active treatment phase of the study. An increased night-time frequency does not seem to occur in those who use the medication during the day nor is there a significant change in serum sodium levels of the group Hoverd and Fowler, If hyponatraemia does occur, it usually happens within the first week or so of starting the medication and the chief symptoms are general malaise, headache and visible oedema of the face and ankles.
Rapid restitution of the sodium level occurs when the medication is stopped. Although the prospect of using a nasal spray to control urge incontinence is obviously more appealing to a patient than performing self-catheterization for the same result, prescription of DDAVP should be restricted to patients who understand that the medication is acting on the kidneys rather than the bladder and it can only be used once in 24 h. Intravesical capsaicin has been used to treat intractable detrusor hyperreflexia due to spinal cord disease on the basis that it has a neurotoxic effect on the C fibre afferents which drive volume determined reflex detrusor contractions.
Capsaicin has a biphasic action; it is initially an irritant, but if applied in sufficiently high concentration its secondary effect is as a selective neurotoxin acting on unmyelinated afferent C fibres. Patients with detrusor hyperreflexia report an initial deterioration in their bladder symptoms lasting up to 10 days followed by a lessening of urgency and frequency which may last up to 6 months, when the instillation needs to be repeated Fowler et al. A controlled study using capsaicin dissolved in alcohol versus the alcohol solution alone has shown capsaicin is the active ingredient de Seze et al.
A study looking at the effectiveness of intravesical capsaicin in a group of patients with multiple sclerosis found it was most effective in those who were still ambulant De Ridder et al. An instillation of lignocaine prior to capsaicin does not appear to lessen the efficacy of the capsaicin and greatly improves the patient's tolerance of the procedure Chandiramani et al. Although intravesical capsaicin has been valuable in demonstrating that the principle of deafferenting the bladder is effective in treating detrusor hyperreflexia, it remains an experimental therapy and in future is likely to be replaced by the ultrapotent capsacinoid, resiniferatoxin.
This is an extract from a plant in the genus Euphorbia and has been demonstrated to be times more neurotoxic than capsaicin for the same degree of pungency as capsaicin. Promising preliminary results have been reported using resiniferatoxin to deafferent the bladder of patients with multiple sclerosis Cruz et al. Thus, it would seem probable that in the not too distant future detrusor hyperreflexia, at least of spinal origin, will be treated by painless deafferenting bladder instillations.
Incomplete emptying can exacerbate detrusor hyperreflexia, and an overactive bladder constantly stimulated by a residual volume will respond by contracting and producing symptoms of urgency and frequency. Incomplete emptying is particularly likely to occur in patients with spinal cord disease due to a combination of detrusor sphincter dyssynergia occurring during attempts to void and poorly sustained detrusor contractions during the voiding phase.
Since there is no medication which causes effective detrusor contraction at a convenient moment the best option to deal with incomplete emptying or retention has been to use intermittent catheterization. Sterile intermittent catheterization was first introduced in the s Guttmann and Frankel, , but it was then found that a clean rather than sterile technique was adequate Lapides et al.
Performed for children with spina bifida and the elderly with disorders of complete bladder emptying Webb et al. Patients are often unaware of the extent to which they empty incompletely, and for this reason measurement of this parameter is the single most important measurement to be made when planning bladder management Fowler, The post-void residual volume may be measured either with ultrasound or using in-out catheterization.hoa10gio.com/includes/map6.php
The advantage of the latter procedure is that it familiarizes the patient with catheterization and so makes teaching the technique of self-catheterization more readily acceptable. A generally accepted figure for significant residual volume is ml. Intermittent catheterization is best performed by the patient themselves who should be taught by someone experienced in the method.
In the UK nurse specialist continence advisors are particularly expert. A main requirement for success with this technique is patient motivation; a degree of physical disability may be overcome provided the patient is sufficiently determined. As a general rule, if patients are able to write and feed themselves they are likely to be able to perform the technique.
Sometimes tremor, impaired visual acuity, spasticity, adductor spasm and rigidity may make it impossible for the patient to do self-catheterization and in such circumstances it may be performed by a partner or care assistant. Since the principle of this technique is to reduce the post-micturition residue, most patients are advised initially to perform the technique at least twice a day. There is, however, no fixed limit on how often it should be performed, but it should be performed regularly. Doing it only very occasionally provides the opportunity to introduce bacteria without the benefit of regular, complete bladder emptying.
Haematuria in the early stages of learning the method is common Bakke, In spinal cord disease, a combination of intermittent self-catheterization together with an oral anticholinergic manages both aspects of bladder malfunction, incomplete emptying and detrusor hyperreflexia. In a patient with a borderline significant residual volume, starting an anticholinergic may have the effect of further impairing bladder emptying.
This should be suspected if the anticholinergic has some initial efficacy which then disappears. Also, it is advisable for a patient who has marked hesitancy and difficulty in initiating micturition to wait to start anticholinergic medication until intermittent catheterization has been established, since there is otherwise a risk of developing complete urinary retention. This combined approach works well in all patients with neurogenical bladder dysfunction who have a combination of hyperreflexia and incomplete emptying, provided the patient is not too severely disabled.
Although a combination of anticholinergic medication together with intermittent catheterization is the optimal management for patients with detrusor hyperreflexia and incomplete bladder emptying, there comes a point when the patient is no longer able to perform self-catheterization, or when urge incontinence and frequency are unmanageable. In patients with spinal cord disease this may be reached when the patient is no longer weight-bearing and is chair-bound and at this stage an indwelling catheter becomes necessary. The most immediate simple solution is an indwelling Foley catheter, but the long-term ill effects of these are well known.
One of the major problems may be leakage of urine around the catheter which occurs when strong detrusor contractions produce a rapid urine flow that cannot drain fast enough. A common reaction to this is to insert a wider-calibre catheter, with the effect that the bladder closure mechanism becomes progressively stretched and destroyed. The detrusor contractions may be of sufficient intensity to extrude the or ml balloon from the bladder, further rupturing the bladder neck. The end result is then a totally incompetent bladder neck and urethra.
Bladder stones and recurrent, resistant infections are also more likely in a bladder with an indwelling catheter. A preferred alternative to an indwelling urethral catheter is a suprapubic catheter which can be inserted under local anaesthetic. However, the procedure should only be undertaken by a trained urologist since there is a danger that bowel overlying the bladder may be punctured, especially in patients with small, contracted bladders. Once in situ , the catheter is left on constant drainage because this minimizes the complications which might otherwise result from volume induced hyperreflexic contractions.
Closing the urethra is a difficult urological procedure which is not usually attempted, so that continence depends on the suprapubic drain remaining patent. Should the catheter become blocked or kinked, the patient leaks urethrally. Although by no means a perfect system, a suprapubic catheter is a better alternative to an indwelling urethral catheter and is often the method of choice in managing incontinence in patients for whom other means are no longer effective Barnes et al. If urge incontinence is the main problem and the bladder empties completely, some men are able to wear an external device attached around the penis.
The simplest and least obtrusive is a self-sealing latex condom sheath, which can be put on each night or kept in place for up to 3 days. More elaborate body-worn appliances are also available, but an expert must fit these. An effective external appliance for women has yet to be devised.
An extradural sacral nerve stimulator can be used to lessen detrusor instability which is proving resistant to anticholinergic medication. The principle by which it is effective is still far from clear but it seems likely that its action is through stimulation of pelvic afferents Lindstrom et al. Implanting a stimulator is a two stage procedure. The first stage when the stimulating lead is inserted through an S3 foramen under local anaesthetic is performed as an out-patient.
The lead is connected to an external stimulator for 3 days and if the patient's symptoms improve significantly during this time, as judged by measurement of residual volumes and diary recorded voided volumes, they are eligible for a permanent stimulator. This device is implanted in a subcutaneous pocket under general anaesthesia and the stimulating lead tunnelled subcutaneously back to the sacrum and the electrode implanted through the foramen.
The stimulator is continuously active giving a 15 Hz pulse to the sacral nerves on one side. The implanted stimulators are expensive and the surgical procedure not without complications, but in well selected cases this form of treatment can greatly improve bladder symptoms Hassouna and Elhilali, ; Dijkema et al.
In patients who have suffered a complete spinal cord transection but in whom the caudal section of the cord and its roots are intact, the implantation of a nerve root stimulator should be considered. This device was pioneered by Professor Giles Brindley and his collaborators, and more than have been implanted worldwide van Kerrebroeck et al. Stimulating electrodes are applied intrathecally to the lower sacral anterior roots S2—S4 and the posterior roots are cut. After the implant, adjustments are made to the stimulation parameters so that the patient obtains the maximum benefit from the stimulator, in terms of making the bladder contract for voiding, assisting defaecation or producing a penile erection.
This is achieved by stimulating individual roots or combinations of roots. The major benefit from the stimulators is an improvement in urinary continence. This is usually achieved by a combination of increasing bladder capacity, due largely to the posterior rhizotomy that is performed, and improving bladder evacuation. Brindley Brindley, has argued that women have greater potential gain from these stimulators than men since incontinence in women is more difficult to manage. Moreover, in men the dorsal rhizotomy that is a necessary part of the procedure will abolish any reflex erections that might otherwise be possible.
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These stimulators are only suitable for patients with complete spinal cord lesions rather than partial cord lesions or progressive neurological disease. Various urological procedures can be carried out to treat incontinence. Although surgical procedures to rectify a bladder disorder causing incontinence in an otherwise fit person are often highly successful, and even following spinal cord injury, a surgical option may be the best solution for long-term bladder management; the same does not apply to those with progressive neurological disease causing incontinence.
For example, at a time when the bladder is becoming unmanageable using a combination of intermittent catheterization and oxybutynin, the patient with multiple sclerosis may only just be managing to remain independent and urological surgery is not appropriate. In practice very few patients with progressive neurological disease affecting bladder control opt for surgery, preferring medical management whilst it is effective and a permanent indwelling catheter, a suprapubic catheter in particular, for long-term use.
The neurology of the bladder has received insufficient attention to date but with the changing emphasis of neurology from a speciality concerned primarily with diagnosis to one promoting the treatment and rehabilitation of patients, the recognition that neurogenic bladder disorders cause major difficulties to patients and are often highly amenable to non-surgical management means this is likely to change.
- Types, symptoms and causes of urinary incontinence.
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One of the problems which may have stunted interest in this area is the very limited repertoire of symptoms which the neurologically impaired bladder can display. However, having read this review, the reader will not be surprised to learn that it is possible to see an entire out-patient clinic of patients with neurogenic bladder disorders and each have a different underlying neurological disease.
All these patients will have in common an anxiety about their bladder dysfunction and eagerness to have it treated. Brainstem activation in women who could left and could not void right. The number —28 refers to the distance in millimetres relative to the horizontal plane through the anterior and posterior commissures z -direction. From Blok et al. Blok et al. Photograph of coronal section of frontal lobes with the shaded area covering the area involved in the lesions described as causing disturbances of micturition, from Andrew and Nathan Andrew and Nathan, The plane of the section is the plane through which leucotomies were made that caused the syndrome they described.
Pie chart showing underlying neurological problems of patients presenting over a week period with bladder symptoms. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account.
Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Neurophysiological control of the bladder—animal experiments. Studies in humans of the neural control of bladder function. Frontal lobe lesions and bladder control. Bladder dysfunction studied urodynamically following cerebrovascular accidents. Epidemiological studies of incontinence following CVA. Urinary incontinence in the elderly and institutionalized. Bladder symptoms in patients with parkinsonism. Spinal cord injury. Progressive spinal cord disease and bladder dysfunction.
Bladder dysfunction in other non-traumatic spinal cord disease. Cauda equina. Bladder dysfunction due to disorders of peripheral innervation. Myotonic dystrophy. Urinary retention in young women. Treatment of neurological disorders of micturition. Neurological disorders of micturition and their treatment Clare J. Dr Clare J. Oxford Academic. Google Scholar.
Article history. Revision Received:. Cite Citation. Permissions Icon Permissions. Abstract An overview of the current concepts of the neurological control of the bladder is given, based on laboratory experiments and PET scanning studies in human subjects. Table 1. Urogenital criteria which favour a diagnosis of multiple system atrophy. View Large. Table 2. View large Download slide. Tethered cord syndrome: an unusual cause of adult bladder dysfunction. Br J Urol. Outcome of shunt operation on urinary incontinence in normal pressure hydrocephalus predicted by lumbar puncture.
J Neurol Neurosurg Psychiatry. Bladder hyperreflexia induced in marmosets by 1-methylphenyl-1,2,3,6-tetrahydropyridine. Neurosci Lett. Allen TD. Psychogenic urinary retention. South Med J. Aminoff MJ, Logue V. Clinical features of spinal vascular malformations. Reversible urinary retention as the main symptom in the first manifestation of a syringomyelia. Andrew J, Nathan PW. Lesions of the anterior frontal lobes and disturbances of micturition and defaecation. Disturbances of micturition and defaecation due to aneurysms of anterior communicating or anterior cerebral arteries.
J Neurosurg. Aranda B, Cramer P. Effects of apomorphine and L-dopa on the parkinsonian bladder. Neurourol Urodyn. Bakke A. Physical and psychological complications in patients treated with clean intermittent catheterization. Scand J Urol Nephrol ; Suppl Myo-, neuro-, gastrointestinal encephalopathy MNGIE syndrome due to partial deficiency of cytochrome-c-oxidase. A new mitochondrial multisystem disorder. Acta Neuropathol Berl. Predicting the outcome of acute stroke: do multivariate models help?
Q J Med. Management of the neuropathic bladder by suprapubic catheterisation. Barrett DM. Psychogenic urinary retention in women. Mayo Clin Proc. Barrington FJF. The relation of the hind-brain to micturition. La retention psychogene d'urine chez la femme: aspects diagnostiques et therapeutiques. J Urol Paris. Genitourinary dysfunction in multiple system atrophy: clinical features and treatment in 62 cases. J Urol. The patient keeps a log of the times and amounts of fluid in, and urine voided, over the course of several days.
In some cases further evaluation may include an assessment of the upper urinary system kidneys, ureter and bladder with either a renal sonogram or CT scan. The bladder and urethra may be studied by cystoscopy. Cystoscopy refers to the direct visual inspection of the bladder and urethra, carried out by inserting a small fiberoptic catheter into the urethra and bladder, which allows direct visualization of these structures.
This is carried out under local anesthetic in an examination room in the office. The goals of treatment are twofold. The second goal, is to help as best as able, with the treatments available, to see if the symptoms of frequency and urgency can be lessened. The following treatment strategies are available to address symptom control:. Anticholinergics : Oxybutynin Ditropan, Oxytrol, Gelnique, Oxytrol patch , Toterodine Detrol , Solifenacin Vesicare , Darifenacin Enablex , Trospium Sanctura , Fesoterodine Toviaz Side effects may include : Dry mouth, constipation, dry eyes, blurred vision, stomach upset, urinary tract infection, incomplete bladder emptying and confusion.
Reasons you cannot take anticholinergic medications : Narrow angle glaucoma, slow stomach emptying, incomplete bladder emptying. Potassium pills need to be changed to liquid form to prevent high potassium levels. Beta 3 adrenergic agonist : Myrbetriq mirabegron Side effects may include : High blood pressure, nose and throat congestion and urinary tract infection.
This is done in the office or in the operating room. The bladder is checked periodically to make sure it is emptying well. The treatment lasts for three to nine months, then repeated as needed.
Types, symptoms and causes of urinary incontinence
After a trial in the office, the generator is implanted in the body. It involves a 30 minute office procedure once a week for 12 weeks then typically monthly treatments. It may be necessary to check with your insurance company to see if it is covered.
As noted above, the main goal is to make sure symptoms are not a sign of an underlying disorder that poses a threat to the health. Measures are then available to make an effort at symptom control. Sometimes symptoms can be improved after several weeks, other times it may take a longer period of time. This website translates English to other languages using an automated tool. We cannot guarantee the accuracy of the translated text. The bladder is a hollow organ in the abdomen that holds urine.
When the bladder is full, it contracts, and urine is expelled from the body through the urethra. Overactive bladder starts with a muscle contraction in the bladder wall. The result is a need to urinate urinary urgency , which is also called urge incontinence or irritable bladder.
While overactive bladder is most common in older adults, the condition is not a normal result of aging. While one in 11 people in the United States suffer from overactive bladder, it mainly affects people 65 and older, although women can be affected earlier, often in their mid-forties. There are two kinds of overactive bladder.
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One without urge incontinence, which is called overactive bladder, dry, and affects two thirds of sufferers; and overactive bladder, wet, which includes the symptoms with urge incontinence leaking or involuntary bladder voiding. Overactive bladder is caused by a malfunction of the detrusor muscle, which in turn can be cased by:. A preliminary assessment for suspected overactive bladder can include a screening questionnaire, a request that the patient maintain a voiding diary for a prescribed number of days, a detailed medical history, and a comprehensive physical examination.
Often a urinalysis, which detects the presence of bacteria in urine and indicates infection, will be ordered to determine if the condition is caused by an infection. A urinalysis also can determine if there is blood or too much protein in the urine, which may indicate kidney or cardiac disease, and can also detect the presence of puss in urine, which is also a sign of infection.
The physical examination for overactive bladder includes checking the neurological status of a patient for any sensory issues, as well as a cough stress test to measure urine loss, whether as an immediate or a delayed reaction. The exam will usually include a check of the abdomen, rectum, genitals and pelvis. Specialized diagnostics for overactive bladder are called urodynamic tests. They assess bladder function, measure the amount of urine after voiding, the degree of incontinence how completely the bladder empties , and bladder irritability.
Measurements are performed by inserting a thin tube through the urethra into the bladder or by performing an ultrasound to acquire an image of the bladder.