Bladder Neck Dyssynergia Research Articles

Diagnosis and treatment of neurogenic bladder secondary to aortic dissection: A 8-year retrospective study at a single center.

To review the characteristics of the neurogenic lower urinary tract dysfunction (NLUTD) secondary to aortic dissection (AD), analyze the clinical features, and discuss the treatment options. Ten individuals complaining of lower urinary tract syndrome following AD were enrolled in this study. Clinical characteristics, urological and neurological symptoms/signs, imaging examination, and intervention were reviewed. Liao's comprehensive classification system was used to precisely assess the lower and upper urinary dysfunction. The urinary symptoms can be varied, including dysuria, incontinence, and frequency. Individuals were divided into the detrusor overactivity (DO) and detrusor underactivity (DU) subgroups. Continence, impaired upper urinary tract functions (renal insufficiency, vesicoureteral reflux, upper urinary tract dilatation, and lower urinary tract functions (DO and/or detrusor external sphincter dyssynergia/detrusor bladder neck dyssynergia, DU, low bladder capacity, and compliance) were examined using video-urodynamics. The principle of treatment is "low-pressure bladder storage with complete bladder emptying,"and close follow-up was recommended due to the volatile course of NLUTD. Both cardiovascular surgeons and urologists should pay attention to the occurrence of NLUTD following AD, and determine the most appropriate therapeutic option.

Evaluation Methods of Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients: A Literature Review

Detrusor sphincter dyssynergia (DSD) is defined as an external urethral sphincter anomalous contraction concomitant to detrusor contraction during voiding, due to a neurological disease. It commonly occurs in suprasacral spinal cord-injured (SCI) patients and can be associated with autonomic dysreflexia. DSD generates risks to the urinary system and overall health; hence, it should be promptly diagnosed and managed. Bladder neck dyssynergia is a condition that should be integrated in DSD assessment. We reviewed the literature indexed in PubMed/Medline on the evaluation methods of DSD in SCI patients. Urodynamics is the mainstay evaluation method and has a prognostic value for the progression of upper urinary tract structural degradation and renal function decline. We found a lack of consensus on the optimal urodynamics configuration when evaluating DSD, especially in obtaining and measuring the signal from external urethral sphincter (EUS) activity. It appears that a combination of recordings of voiding cystourethrography and EUS electromyography, either with or without EUS pressure measurement, is the most accurate method available for evaluating DSD. While gathering articles, we came across an interesting approach in evaluating DSD in the past: urodynamics coupled with ultrasound imaging. Despite being considered valuable from a diagnostic standpoint by some prominent authors, it is no longer represented in the current literature. In addition to the instrumental diagnosis, health professionals should consider additional clinical features when evaluating and managing DSD in SCI patients, to design a customized plan to achieve the best compromise between quality of life and urinary system protection.

External Sphincter Injection of Onabotulinum-A Toxin in Treatment of Children with Bladder- Sphincteric Dyssynergia

Abstract Background: The first application of Onabotulinum-A Toxin in urology was its injection into the urinary sphincter to treat neurogenic detrusor-sphincter dyssynergia in quadri-plegic men. Since that first report by Dyskatra et al., in 1988, the results of focal Onabotulinum-A Toxininjections into the sphincter, the bladder wall and lately into the prostate have raised the interest of the urology community in this promising new therapeutic modality. This is an evidence-based review of the current indications, techniques and outcomes of Ona-botulinum-A Toxin injections into the urethral sphincter. Aim of Study: We evaluated the effect of detrusor injection of onabotulinum-A toxin into the urethral urinary sphincter in children with bladder-external sphincter dyssynergia to decrease urethral resistance and improve voiding. Material and Methods: Prospective treatment was per-formed in 25 children 4 to 15 years old (mean age 7) with bladder-neck dyssynergia using onabotulinum-A toxin. Pre-operatively all children were evaluated by ultrasound, voiding cystourethrography, excretory urography, magnetic resonance imaging and urodynamic studies, including pressure flow, electromyography and uroflowmetry. Using a rigid pediatric endoscope and a 4Fr injection needle 50 to 100 IU onabotu-linum-A toxin was injected into the external sphincter at the 5 and 7 o'clock positions. Follow-up was 6 to 15 months. Repeat injections every 6 months were given according to the response with a maximum of 3 injections. Results: Immediately after onabotulinum-A toxin injection all except 1 patient were able to void without catheterization. No acute complications occurred. Postoperatively post-void residual urine decreased by 30%, detrusor leak point pressure decreased significantly by a mean ± SD of 66±18 vs 37±4cm H2O and uroflowmetry showed a marked increase in maximum urine flow of 7±2 vs 17.3±8ml per second. Conclusions: Urethral sphincter onabotulinum-A toxin injection could be considered a reliable treatment modality in children with nonneurogenic neurogenic bladder after the failure of conservative therapy.

Urodynamic findings and urologic management of central cord syndrome

Purpose: Central cord syndrome is the most common incomplete spinal cord injury, although urodynamic data on this subset of patients is lacking. We aim to determine the typical urodynamic features associated with this condition. Methods Consecutive patients undergoing urodynamic studies in a tertiary spinal cord unit between 2014 and 2018 were retrospectively reviewed to identify those with central cord syndrome. Charts were evaluated for demographics, spinal cord injury classification, symptoms, urodynamic parameters and treatment. Data were analysed using descriptive statistics. Results: A total of 131 consecutive patients undergoing urodynamic studies were reviewed and 33 were identified with central cord syndrome. Mean age was 46 years and 91% were male. The predominant spinal cord injury classification was American Spinal Injury Association D (52%). Overall, 94% (31/33) reported volitional voiding and normal bladder sensation. Video-urodynamics demonstrated neurogenic detrusor overactivity in 70% (23/33) of patients, with 15% (5/33) demonstrating leakage with neurogenic detrusor overactivity and 21% (7/33) having reflex emptying. In total, 94% (31/33) of patients had normal compliance, 42% (14/33) of patients had detrusor sphincter or bladder neck dyssynergia and 60% (20/33) had an alteration to their management plan following urodynamic study. Conclusion: There is discordance between subjective patient-reported symptoms and objective urodynamic findings. About two-fifths of patients may have a potentially unsafe urodynamic bladder profile and urodynamics studies resulted in a change in bladder management in the majority of patients. Urodynamic assessment of patients with central cord syndrome is essential to determine which patients require further intervention. Level of evidence: Not applicable for this multicentre audit.

MP68-09 URODYNAMICS IN UNDERACTIVE BLADDER: ABNORMAL VOLUME MANAGEMENT VS. DETRUSOR DEFICIENCY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Basic Research & Pathophysiology II1 Apr 2016MP68-09 URODYNAMICS IN UNDERACTIVE BLADDER: ABNORMAL VOLUME MANAGEMENT VS. DETRUSOR DEFICIENCY Gerard Pregenzer, Jason K Frankel, and Phillip Smith Gerard PregenzerGerard Pregenzer More articles by this author , Jason K FrankelJason K Frankel More articles by this author , and Phillip SmithPhillip Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1346AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Underactive bladder (UAB) is an emerging concept proposed to describe a symptom complex of perceived difficulties with bladder emptying. Previous studies have shown it to not strongly correlate with detrusor underactivity (DU) or diminished contractility (DC). We reviewed urodynamic records of patients with UAB (voiding hesitancy, abnormal stream, or incomplete emptying sensations) in an initial attempt to identify pathophysiologic groupings. METHODS 501 urodynamic records were reviewed, of which 414 were of non-neurogenic patients who attempted to void. Records were sorted by UAB +/-, urodynamic observations, Watts Factor (WF), voiding efficiency (VE) and postvoid residual volume (PVR). Associations were sought using contingency tables and comparative statistics. RESULTS 125 patients reported symptoms characterizing UAB. Out of this group, only 42 were found to have DU, making the positive predictive value (PPV) of UAB for DU 33.6%. By contrast, 46 patients with UAB were found to have bladder outlet obstruction (BOO), 31 dysfunctional voiding (DV), 10 stress urinary incontinence (SUI) and 4 bladder neck dyssynergia (BND). No significant association between UAB and DC was found; this was true whether using the 25th percentile or one standard deviation below the mean for WF. No difference in VE was noted between the UAB and no-UAB groups. Mean PVR, however, was significantly elevated in UAB at 253 ml versus 130 ml in no-UAB. CONCLUSIONS UAB is associated with a variety of urodynamic observations, and is not predictive of a weak bladder or detrusor underactivity. It is associated with elevated PVR yet a similar VE as non-UAB symptoms, indicating greater bladder volumes at voiding initiation. UAB therefore may be an indicator of abnormally high operational bladder volumes rather than an inherent voiding deficiency. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e892 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Gerard Pregenzer More articles by this author Jason K Frankel More articles by this author Phillip Smith More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Predictors of outcome for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia in men with spinal cord injury

This is a retrospective study. The objective of this study was to determine outcome predictors for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury. Botulinum toxin type A (100 Units Botox, Allergan) was injected into the external urethral sphincter using a transperineal approach under EMG guidance. Treatment was indicated if DSD was found on urodynamic testing with a post-void residual volume (PVR) above 100 ml. Urodynamic tests and cystourethrograms were performed at baseline. Dysuria (scale of 1-5) and PVR (48- h bladder diary) were evaluated at baseline and 1 month. The outcome was deemed excellent when PVR was equal to or <100 ml and 20%, and dysuria rated <3. Seventy-two men with tetraplegia and 27 with paraplegia were included. There were significant reductions in PVR (from 227 to 97 ml and 63% to 27%) and dysuria (from 4.3 to 2.3). Excellent outcomes were found in 48 patients (48%), and the duration of effectiveness was 6.5 months. The need for catheterisation was decreased or eliminated in 18 patients. Vesicoureteral reflux disappeared in some patients. Poor outcome was significantly related to the presence of bladder neck dyssynergia and the absence of detrusor contraction in standard cystometry. Outcome was also related to the severity of DSD, with a strong correlation between PVR before and after injection (r=0.58). Injections were repeated in 36 patients and yielded similar outcomes in most cases (89%). Detrusor contractions (odds ratio=8.6) and normal bladder neck activity (odds ratio=7.1) are strong predictors of excellent outcome.

169 Pathophysiology and severity based proposed urodynamic classification of detrusor bladder neck dyssynergia

169 Pathophysiology and severity based proposed urodynamic classification of detrusor bladder neck dyssynergia

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Pathophysiology and severity based proposed urodynamic classification of detrusor bladder neck dyssynergia

Aims : to propose a novel urodynamic classification of neurogenic bladder neck dysfunction due to suprasacral lesions. Material and Methods: Thirty three male patients with suprasacral infrapontine lesion and detrusor bladder neck dyssynergia confirmed upon cystourethrography were classified as following: Group O [Pdetopen prior to Pdetmax , Tqmax ≥ 1/3 Tq at free uroflow, incomplete bladder neck opening during cystourethrography], Group IA (increased Topen, high amplitute terminal neurogenic detrusor overactivity –TNDO-, Pdetopen after Pdetmax with abdominal straining during pressure flow study), Group IB (increased Topen, high amplitude TNDO, Pdetopen after Pdetmax without abdominal straining during pressure flow study), Group II (high pressure and high velocity TNDO with Pdetopen after Pdetmax) and Group III (active reduced compliance with detrusor leak point pressure at or after Pdetmax). Results: Absence of free urination was reported at 0% (0/2), 16.67% (2/12), 66.67% (4/6), 100% (4/4) and 100% (9/9) of group O, IA, IB, II and III, respectively. Mean value of maximum free flow (Qmax) was 17.4, 12.4 and 4.1 ml/sec for group O, IA and IB, respectively. Interrupted voiding pattern during free uroflow, at percentage greater than 50% of all the recorded flows per patient, was 0% (0/2), 100% (10/10) and 100 % (2/2) respectively. Spastic paraplegia was present in 0%(0/2), 8.3%(1/12), 83.3%(5/6), 100%(4/4) and 100%(9/9), bilateral normal perineal sensation (PS) was recorded at 50%(1/2), 25%(3/12), 16.7%(1/6), 0%(0/4), 0%(0/9) while “normal” bladder sensation during cystomanometry was found at 100%(2/2), 50% (6/12), 20%(1/6), 0%(0/4), 0%(0/10) of groups O, IA, IB, II and III, respectively. Conclusions: The classification proposed in this pilot study represents five increasing severity degrees of NDO with progressively increased degree of detrusor bladder neck dyssynergia. Σκοπός: Ουροδυναμική ταξινόμηση της νeυρογeνούς δυσσυνέργeιας eξωστήρα κυστικού αυχένα (DBND). Υλικό - Μέθοδος : Αναδρομικά, 33 άντρeς μe eπιβeβαιωμένη (MRI σπονδυλικής στήλης) υπeριeρή υπογeφυρική βλάβη του νωτιαίου μυeλού ταξινομήθηκαν μe βάση τις ουροδυναμικές παρατηρήσeις στην ομάδα O [Pdetopen (≥ 40 cm H2O) πριν την Pdetmax, Tqmax > 1/3 Tq στην eλeύθeρη ουροροομeτρία και ατeλής ή καθυστeρημένη διάνοιξη του κυστικού αυχένα στην κυστeοουρηθρογραφία κατά την ούρηση], την ομάδα ΙΑ [αυξημένο Topen, μeγάλου eύρους τeλική νeυρογeνή υπeρλeιτουργία του eξωστήρα (TNDO) και κοιλιακή συμμeτοχή στην ούρηση], την ομάδα ΙΒ [αυξημένο Topen, μeγάλου eύρους τeλική νeυρογeνής υπeρλeιτουργία του eξωστήρα (TNDO) δίχως κοιλιακή συμμeτοχή στην ούρηση], την ομάδα ΙΙ (υψηλών πιέσeων και σύντομης διάρκeιας TNDO) και την ομάδα ΙΙΙ (δυναμική eλαττωμένη eυeνδοτότητα μe πίeση διαφυγής eξωστήρα (DLPP) υψηλών πιέσeων κατά ή μeτά την Pdetmax. Αποτeλέσματα : Eλeύθeρη ούρηση παρουσίασe το 100% (2/2), 83.3% (10/12) και 33.3% (2/6) των ομάδων Ο, ΙΑ και ΙΒ, αντίστοιχα. Η μέση μέγιστη ροή των ούρων στην eλeύθeρη ουροροομeτρία υπολογίστηκe στο 17.4, 12.4 and 4.1 ml/sec, αντίστοιχα. Διακοπτόμeνη ούρηση σe ποσοστό μeγαλύτeρο του 50% των καταγeγραμμένων ουρήσeων ανά ασθeνή, παρατηρήθηκe στο 0% (0/2), 100% (10/10) και 100% (2/2), αντίστοιχα. Σπαστική παραπληγία παρατηρήθηκe στο 0%(0/2), 8.3%(1/12), 83.3%(5/6), 100%(4/4) και 100%(9/9), αμφοτeρόπλeυρα φυσιολογική αισθητικότητα πeριπρωκτικά (PS) καταγράφηκe στο 50%(1/2), 25%(3/12), 16.7%(1/6), 0%(0/4), 0%(0/9) eνώ φυσιολογική αισθητικότητα της κύστeως διαπιστώθηκe στο 100% (2/2), 50% (6/12), 20% (1/6), 0% (0/4), 0% (0/10) των ομάδων Ο, ΙΑ, ΙΒ, ΙΙ και ΙΙΙ, αντίστοιχα.

A 20‐year follow‐up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury

To assess the long-term (20 years) effectiveness of the UroLume wallstent(TM) (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in patients with spinal cord injury (SCI). Twelve patients with quadriplegia secondary to SCI underwent external striated sphincter stenting with the UroLume wallstent in place of sphincterotomy for DESD ≈ 20 years ago. The mean (range) age was 41.8 (26-65) years. Eleven patients had cervical level injury whilst one had a thoracic injury. All the patients were shown to have high-pressure neurogenic detrusor overactivity and DESD with incomplete emptying on preoperative video-cystometrograms (VCMG). Six of the 12 patients have now been followed-up for a mean (range) of 20 (19-21) years. Of the remaining six, two were lost to follow-up at 1 and 3 years, but both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within 1 year of insertion. Another patient with an adequately functioning stent died 7 years after stent insertion from a chest infection. The twelfth patient developed bladder cancer 14 years after stent insertion and underwent cystectomy with urinary diversion. VCMG follow-up of the six patients showed a significantly sustained reduction of maximum detrusor pressure and duration of detrusor contraction at the 20-year follow-up. Five of these six patients developed bladder neck dyssynergia of varying degrees as shown on VCMG within the first 9 years of follow-up. All were successfully treated with bladder neck incision (BNI) where the last BNI needed was at 12 years. We did not encounter any problem with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. Urethral stenting using the UroLume wallstent is effective in the management of DESD in patients with SCI and provides an acceptable long-term (20-year follow-up) alternative to sphincterotomy. The failures manifest within the first few years and can be managed easily with stent removal without any significant problems. Bladder neck dyssynergia was the long-term complication which was treated successfully with BNI. It has no significant interference with erectile function, being reversible, minimally invasive and has a shorter hospital stay.

Intraprostatic and Bladder-Neck Injection of Botulinum A Toxin in Treatment of Males with Bladder-Neck Dyssynergia: A Pilot Study

ObjectivesTo determine if intraprostatic and bladder-neck injection of botulinum toxin A (BoNTA) in patients with bladder-neck dyssynergia (BND) is a feasible alternative therapy. MethodsMales diagnosed with BND on video-urodynamics showing delayed and incomplete bladder-neck opening during voluntary voiding were recruited. Eight consenting patients had 100U of BoNTA injected transurethrally into the bladder neck and proximal prostatic urethra laterally (10U/ml×10 sites). Patients were assessed at preinjection, at 1, 6, and 2 wk, and at 4 weekly intervals thereafter by means of uroflometry, 3-d frequency–volume chart, and International Prostate Symptom Score (IPSS)-Quality of life (QoL) questionnaire. Urodynamic studies were done at screening and 6 wk postprocedure. ResultsThe mean age was 36.9 yr. Mean duration of symptoms was 6.5 yr. At 6 wk, 7 of 8 (87.5%) patients had>50% reduction of IPSS from baseline. Overall mean reduction was 50% (19.9±2.7 vs. 9.9±1.7, p=0.036). Six of 8 (75.0%) patients had>3ml/s increase in peak urinary flow rate with overall mean peak urinary flow rates improving from 11.6 to 17.2 (p=0.048) at 6 wk. Micturition frequency decreased 46% (13.6 vs. 7.6, p=0.036) and IPSS-QoL scores improved 47% (4.9±0.2 vs. 2.6±0.6, p=0.048). None reported any adverse effects or ejaculation dysfunction. Three of 8 patients had recurrence of symptoms after a mean of 8 mo. ConclusionThese results are encouraging. Larger, randomized, placebo-controlled trials could be worthwhile to verify these results.

The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up.

To assess the long-term effectiveness of the UroLume trade mark wallstent (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in quadriplegic patients. Twelve patients with quadriplegia secondary to spinal trauma underwent external striated sphincter stenting with the UroLume wallstent instead of an external sphincterotomy for DESD (mean age 41.8 years, range 26-65). The level of injury was C4 in two, C5 in four, C6 in four, C7 in one and T6 in one. All patients were shown by preoperative video-cystometrography (VCMG) to have DESD and high-pressure, hyper-reflexic bladders with incomplete emptying. Seven of the 12 patients had a mean (range) follow-up of 12.7 (12.17-13.6) years; two others were lost to follow-up at 1 and 3 years and both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within a year of insertion. Another patient with an adequately functioning stent died 7 years after surgery (chest infection). Urodynamic follow-up of the seven patients showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction at> 10 years of follow-up. Five of the seven patients developed bladder neck dyssynergia of varying degrees, as shown on VCMG; all were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. Subsequent bladder neck dyssynergia is the main complication but this can be managed successfully with bladder neck incision. Importantly, unlike sphincterotomy, there is no significant interference with erectile function. Also, the procedure is reversible, minimally invasive and requires a shorter hospital stay.

Video urodynamics using transrectal ultrasonography for lower urinary tract symptoms in women.

To understand the properties of lower urinary tract disorders in women, we evaluated 60 female patients with lower urinary tract disorders or symptoms of recurrent cystitis by free uroflowmetry and video urodynamics using transrectal ultrasonography (VU-TRUS). Results of urodynamic studies or symptoms of stress incontinence were used to divide 60 women into 7 normal controls and 53 with voiding dysfunctions. In normal controls, VU-TRUS showed that the mean posterior urethrovesical angle and anteroposterior diameter of the proximal urethra at maximum flow was 151.4 degrees and 4.9 mm, respectively. In patients with voiding dysfunction, VU-TRUS during voiding revealed various urethral abnormalities, including 16 detrusor sphincter dyssynergia, 4 detrusor bladder neck dyssynergia, and 13 insufficient opening of the entire urethra. VU-TRUS also showed pelvic floor abnormalities, including 24 urethral hypermobilities (group 1) and 11 cystoceles (group 2). Eighteen patients had neither urethral hypermobility nor cystocele (group 3). Major pressure-flow abnormalities in the 53 patients with voiding dysfunctions were weak detrusor (72%) and/or bladder outlet obstruction (25%). There were no significant differences in the distribution of the pressure-flow abnormalities among the three groups. However, the mean values of abdominal pressure at maximum flow of group 1 (20.9 cm H(2)O) and group 2 (17.9 cm H(2)O) were significantly higher than that of group 3 (6.3 cm H(2)O; each P < 0.05). The mean values of residual urine volume of group 2 (60.8 mL) and group 3 (77.6 mL) were significantly higher than that of group 1 (23.5 mL; each P < 0.05). The symptoms of women with lower urinary tract disorders were frequently accompanied by urethral and/or pelvic floor abnormalities during voiding that were clearly detected by VU-TRUS. VU-TRUS is useful for objective evaluation of female lower urinary tract symptoms.

The nature of detrusor bladder neck dyssynergia in non-neurogenic bladder dysfunction

There have been two major opinions on the pathology or nature of the bladder neck contracture. One is an organic fibrosis, and the other is an accentuated sympathetic nervous function, or detrusor bladder neck dyssynergia. The existence of active detrusor bladder neck dyssynergia in neurogenic bladder was reported in a urodynamical manner using microtip transducer catheters. However, it has not been confirmed whether or not detrusor bladder neck dyssynergia is responsible for bladder neck contracture in patient without neurogenic bladder. The present study was designed to determine by means of video urodynamic study whether or not bladder neck contracture would be of the same nature as detrusor bladder neck dyssynergia in non-neurogenic bladder subjects. The study included 32 male subjects of 16–84 years old (average 52.3): 17 bladder neck contracture subjects including 7 subjects associated with minimum complications (4 with trapped benign prostatic hyperplasia and 3 with incomplete neurological lesion) and 15 non-bladder neck contracture subjects (10 healthy volunteers, 2 chronic prostatitis, 3 prostatodynia). A 5-microtip transducer catheter was used to measure the pressure in the bladder and at the bladder neck, the external urethral sphincter and the bulbous urethra during voiding. Proper localization of the transducers was done with an image intensifier. Bladder outlet obstruction localized at the bladder neck (diameters smaller than 0.75 cm) on voiding cystourethrogram was defined as bladder neck contracture. Detrusor bladder neck dyssynergia was defined where pressures were higher at the level of bladder neck than in the bladder during detrusor contraction. An alpha-blocker, terazosin hydrochloride (0.5 mg, b.i.d., two weeks), was orally administered to subjects judged to have detrusor bladder neck dyssynergia by the above methods for the purpose of confirming whether detrusor bladder neck dyssynergia was really due to accentuated sympathetic nervous function. Detrusor bladder neck dyssynergia was found in seven cases with bladder neck contracture: 6 cases with bladder neck contracture with minimum complications and only 1 case with bladder neck contracture without complications ( p<0.01). Detrusor bladder neck dyssynergia was found at the beginning and ending of micturition, but not at maximum flow. In six cases with detrusor bladder neck dyssynergia, the condition disappeared after terazosin. In conclusion, detrusor bladder neck dyssynergia was not thought to be a major factor of voiding dysfunction in bladder neck contracture in non-neurogenic bladder. In the presence of sympathetic hyperactivity or in cases with increased number of alphareceptors, detrusor bladder neck dyssynergia occurs, being predominantly noted in trapped benign prostatic hyperplasia and neurological disorder patients.

The Value of Sympathetic Skin Response Recordings in the Assessment of the Vesicourethral Autonomic Nervous Dysfunction in Spinal Cord Injured Patients

Purpose We assessed the degree of sparing of the descending sympathetic spinal tract and correlated these findings with bladder neck function in spinal cord injured patients. Materials and Methods Sympathetic skin responses of the right hand and foot were recorded and compared to the urodynamic findings in 27 spinal cord injured patients. Results All tetraplegic and paraplegic patients with a lesion above the T6 level who presented with bladder neck dyssynergia associated with autonomic hyperreflexia had abnormal sympathetic skin responses in the right hand and foot. All patients with a lesion below the T6 and above the T12 levels with an abnormal sympathetic skin response in the right foot also had bladder neck dyssynergia. Conclusions Evidence is presented that the integrity of the descending sympathetic spinal tract is necessary for a synergic function of the vesicourethral complex and that sympathetic skin responses are of value in the diagnosis of bladder neck dyssynergia. For lesions below the T12 level other investigative methods to exclude bladder neck dyssynergia are necessary.

Botulinum-A Toxin as a Treatment of Detruosor-Sphincter Dyssynergia: A Prospective Study in 24 Spinal Cord Injury Patients

Purpose The paralytic effect of botulinum-A toxin injections on the external urethral sphincter was investigated prospectively in patients with neurogenic voiding disorders. Materials and Methods Transurethral versus transperineal botulinum-A toxin injections were performed in 24 spinal cord injury male patients with detrusor-sphincter dyssynergia and the respective efficacy was compared. Results In 21 of 24 patients detrusor-sphincter dyssynergia was significantly improved with a concomitant decrease in post-void residual volumes in most cases. Botulinum-A toxin effects lasted 3 to 9 months, making reinjections necessary. Conclusions Although costly, botulinum-A toxin injections, which aim at suppressing detrusor-sphincter dyssynergia but not bladder neck dyssynergia, appear to be a valid alternative for patients who do not desire surgery or are unable to perform self-catheterization.

An Increase of Neuropeptide Y But Not Nitric Oxide Synthase-Immunoreactive Nerves in the Bladder Neck from Male Patients with Bladder Neck Dyssynergia

Purpose To determine the distribution of neuropeptides in male patients with bladder neck dyssynergia and benign prostatic hyperplasia. Materials and Methods Bladder neck tissue, obtained from male patients with bladder neck dyssynergia (BND) and control patients with benign prostatic hyperplasia (BPH), was studied immunohistochemically for protein gene product 9.5 (a general neuronal marker), vasoactive intestinal polypeptide, neuropeptide Y, calcitonin gene-related peptide, substance P, growth associated protein 43 and nitric oxide synthase. Results In the bladder neck from control patients, the greatest density of nerves contained protein gene product 9.5, followed in decreasing order by neuropeptide Y; vasoactive intestinal polypeptide; calcitonin gene-related peptide; nitric oxide synthase; substance P and serotonin. The neuropeptides were found in the smooth muscle and were also associated with blood vessels. In patients with BND there was a statistically significant increase (P less than 0.05) in the density of protein gene product 9.5- and neuropeptide Y-immunoreactive nerves in the smooth muscle and the base of the mucosa but not in blood vessels in the bladder neck, while the density of the other neuropeptides studied, nitric oxide synthase and serotonin did not significantly change from that of control tissue. Growth associated protein 43-immunoreactive nerves were absent from the bladder neck from both groups of patients. Conclusion It is suggested that the increase in density of protein gene product 9.5- and neuropeptide Y-immunoreactive nerves, part of the sympathetic contractile system of the bladder neck, may exacerbate bladder outlet obstruction and thus play a role in the pathogenesis of BND.

An Increase of Neuropeptide Y But Not Nitric Oxide Synthase-Immunoreactive Nerves in the Bladder Neck from Male Patients with Bladder Neck Dyssynergia

An Increase of Neuropeptide Y But Not Nitric Oxide Synthase-Immunoreactive Nerves in the Bladder Neck from Male Patients with Bladder Neck Dyssynergia

Detrusor Bladder Neck Dyssynergia Revisited

To our knowledge, direct measurement of active closure of the bladder neck during bladder contraction resulting in bladder neck dyssynergia and outflow obstruction has not yet been demonstrated. A total of 34 spinal cord injury patients underwent urodynamic investigation with 2 micro-transducer catheters in the urethrovesical and anorectal regions, respectively. Proper localization of the transducers was done with an image intensifier. The respective role of the striated and smooth muscles on bladder neck activity was evaluated after pudendal nerve blocks and phentolamine injections. Of the patients 25 had active bladder neck dyssynergia with concomitant detrusor-sphincter dyssynergia. Pressures were higher in the bladder neck than in the bladder. Pudendal blocks abolished detrusor-sphincter but not bladder neck dyssynergia, which was decreased by additional phentolamine but only in patients in whom bladder neck dyssynergia was associated with autonomic hyperreflexia. Evidence is presented that active bladder neck dyssynergia may exist in patients with a neurogenic bladder and that it is seemingly dependent on al-postsynaptic and a2-presynaptic adrenoreceptors.

Three-dimensional imaging of the prostatic urethra--an exciting new tool.

To evaluate the technique of three-dimensional (3-D) ultrasound imaging of the urethra and its application in both research and clinical practice. The study involved 23 patients: 10 with benign prostatic hyperplasia, four with urethral strictures, three post-insertion of prostatic stents, one with bladder neck dyssynergia, three post-transurethral resection of the prostate, and two with non-urological conditions. A transrectal ultrasound scan was initially performed to acquire a series of images of the urethra. These images were then reconstructed into a 3-D format. The 3-D image of the urethra could be rotated on screen and viewed from any angle. The image could also be sliced at any plane to reveal the sectional view. This new tool represents a major advance in imaging techniques and promises to provide new knowledge in understanding the hydrodynamics of the lower urinary tract. The precise geometry of the 3-D urethra will also help in the design of new stents.