Detrusor-external Sphincter Dyssynergia Research Articles

Functional urinary outlet obstruction causing urosepsis in a male multiple sclerosis patient

Detrusor-external sphincter dyssynergia (DESD) is a neuropathic disorder of micturition that exists when the simultaneous contractions of the detrusor muscle and external urethral sphincter oppose each other. When the external urethral sphincter contracts during a detrusor contraction, functional urinary outflow obstruction occurs by the increased urethral resistance. This loss of coordination between the bladder and its outlet is associated with a high risk for serious urologic complications, such as vesicoureteral reflux, hydronephrosis, and urosepsis. This report describes a male multiple sclerosis patient with DESD who developed functional outlet obstruction with urosepsis and discusses the diagnosis and treatment of this potentially life-threatening voiding dysfunction.

Bladder and Sphincter Behavior in Patients With Spinal Cord Lesions

To ascertain the relationship between the clinical neurological level, and bladder and sphincter behavior, the video-urodynamic studies of 489 patients with spinal cord lesions due to a variety of causes were retrospectively analyzed. Patients were classified based on the clinical neurological level, etiology of the lesion and presence or absence of signs of sacral cord involvement. Urodynamic findings were classified as either detrusor hyperreflexia, detrusor-external sphincter dyssynergia, detrusor areflexia or normal. The results indicate that although there was a general correlation between the neurological level of injury and the expected vesicourethral function, it was neither absolute nor specific. For example, 20 of 117 cervical cord lesions had detrusor areflexia, 42 of 156 lumbar cord lesions had detrusor-external sphincter dyssynergia and 26 of 84 sacral cord had either detrusor hyperreflexia or detrusor-external sphincter dyssynergia. However, if one considers the presence of neurological abnormalities, 84% of the suprasacral cord lesions with detrusor areflexia have sacral cord signs. In contrast, all suprasacral cord lesions with no evidence of sacral cord involvement have either detrusor hyperreflexia or detrusor-external sphincter dyssynergia. The positive predictive value for positive sacral cord signs and detrusor areflexia was 87%. The positive predictive value for negative sacral cord signs and detrusor hyperreflexia/detrusor-external sphincter dyssynergia was 81%. These data suggest that the clinical neurological examination alone is not an adequate barometer to predict neurourological dysfunction and that video-urodynamic evaluation provides a more precise diagnosis for each patient.

Clinical Manifestation of Human T-Cell Lymphotropic Virus Type-I-Associated Myelopathy and Vesicopathy

Patients with human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy (HAM) sometimes have accompanying voiding disturbances. We performed clinical surveys and urodynamic examinations on 25 untreated patients with HAM. Although 4 cases (16%) were entirely aware of urinary symptoms, the onset of urinary symptoms preceded other pyramidal symptoms in 6 cases (24%). All cases suffered from dysuria. The cause of dysuria was thought mainly to be detrusor external sphincter dyssynergia, but in some cases an underactive detrusor and poor opening of the bladder neck at voiding were also the causes of dysuria. There was a tendency for urinary dysfunction to become worse as the primary disease progresses. Patients with HAM must be carefully followed up by urologists in order to prevent deterioration of the urinary tract.

Non‐neurogenic neurogenic bladder: The relationship between intravesical pressure and the external sphincter electromyogram

AbstractWe retrospectively reviewed the urodynamic studies of 14 patients: 3 males and 11 females, previously diagnosed clinically and urodynamically as having non‐neurogenic neurogenic bladder. The mean age of the patients was 10 years (range 4–24 years). We identified 3 urodynamic features in this patient population that are distinct from those seen in patients with true detrusor‐external sphincter dyssynergia: (1) quieting of the external sphincter electromyogram (EMG) immediately prior to the onset of a detrusor contraction, (2) quieting of the EMG during the upslope of a detrusor contraction, and (3) augmented EMG activity during the downslope of the detrusor contraction. Although both involve incoordinate bladder and pelvic floor/external sphincter activity, a simple cystometrogram with EMG may allow reliable differentiation between true detrusor‐external sphincter dyssynergia and non‐neurogenic neurogenic bladder.

Urinary Dysfunction in Transverse Myelitis

Six men and 2 women with a history of transverse myelitis and persistent lower urinary tract symptoms underwent neurourological evaluation. Of the patients, 4 were neurologically intact, while the remainder had residual neurological deficits. Urodynamic studies revealed detrusor-external sphincter dyssynergia in 6 patients. Two patients had detrusor hyperreflexia, of whom 1 also had an incompetent sphincter. Erectile or ejaculatory dysfunction was reported by 3 men. We conclude that prolonged bladder and sexual dysfunction, caused by spinal cord inflammatory insult, may persist despite a systemic neurological recovery. Therefore, bladder management guided by initial and followup urodynamics is recommended.

膀胱利尿筋尿道括約筋協調不全の交感神経α<sub>1</sub>-遮断薬による治療効果

Effects of adrenergic alpha-1-blocking agent, prazosin, in the treatment of detrusor external-sphincter dyssynergia (DSD) were evaluated in both experimental and clinical aspects. Experimentally, in the urethral pressure profile in dogs, the maximum urethral closing pressure was depressed after intravenous injection of 1 mg prazosin. When experimental DSD was obtained in dogs by stimulating electrically the unilateral 2nd sacral root, intra-venous injection of 1 mg prazosin inhibited contraction of the external urethral sphincter. Clinically, 74 patients with DSD based on neurogenic bladder from cerebral vascular attack (CVA) (13 cases) and spinal cord injury (61 cases) were retrospectively surveyed in terms of therapeutical effects of prazosin for DSD. Spinal cord injury was subdivided to 4 groups for clinical evaluation; cervical cord injury (C) with complete paralysis, thoracic cord injury (Th) with complete paralysis, lumbar cord injury (L) with complete paralysis and spinal cord injury with incomplete paralysis. Patients with CVA and spinal cord injury with incomplete paralysis showed good response rates in subjective improvement, 69% and 60% respectively. However, those with spinal cord injury with complete paralysis showed a poor response (28% for C, 23% for Th and 14% for L). The amount of residual urine significantly decreased after treatment, in all the groups except that of lumbar cord injury with complete paralysis. In all the groups, however, even after the drug treatment the amount of residual urine ranged from 80 to 170 ml and the rates of needing clean intermittent catheterization unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Scrotal fistula from urethro-vasal reflux in paraplegia

A case is presented of a paraplegic in whom urethro-vasal reflux and scrotal fistula developed. Urodynamics testing showed a hyperreflexic bladder with detrusor-external sphincter dyssynergia.

External Sphincter Dyssynergia: An Abnormal Continence Reflex

Some of the characteristics of detrusor-external sphincter dyssynergia were examined in 14 patients with traumatic upper motor neuron lesions within 44 weeks of injury. The sacral evoked response latencies of the male patients were shortened at any time after injury. A continence reflex could be demonstrated in most patients at any time after injury. Comparing averaged values for the group at 4-week intervals, resting pressure at the external urethral sphincter and post-void residual volumes reached nadirs at 12 weeks while voiding efficiency peaked at this time. Thus, voiding function appears to be optimal 12 weeks after injury. During reflex detrusor activity, increases in external urethral sphincter electromyographic activity and external urethral sphincter pressure were associated clearly with a positive slope of the intravesical pressure trace, whereas decreases in both parameters were associated with a negative slope. Voiding occurred only during a negative slope. Although propantheline induced detrusor areflexia, episodic peaks in external urethral sphincter pressure and electromyographic activity continued to occur. We propose that external sphincter dyssynergia, which is independent of detrusor contraction, is the continence reflex exaggerated owing to the loss of supraspinal influences. We believe that the multiple patterns of dyssynergia described previously by others are variations, largely owing to technique, of the single pattern we have observed. The observation of synergic-like urethral responses in some patients during a negative slope of the intravesical pressure, even with complete suprasacral spinal lesions, implies existence of a pathway for synergic-like voiding in the spinal cord.

The Neurophysiology of Micturition: A Clinical Study of 550 Patients

AbstractDetailed urodynamic and neurologic evaluation of 550 patients was reviewed with the intention of shedding light on the understanding of the neurophysiologic pathways involved in micturition. On the basis of our data the following conclusions were made: 1) normal micturition is a brain stem reflex rather than a simple sacral reflex, 2) interruption of this sacral-to-brain stem reflex pathway results in uncoordinated voiding (detrusor-external sphincter dyssynergia), 3) anatomically separate neural centers control the activity of the detrusor muscle and the external urethral sphincter, and 4) although the pudendal and pelvic nuclei are located in the sacral spinal cord they are anatomically separable from one another.

The development of reflex bladder activity following spinal cord injury in cats and a method to control it

AbstractSpinal cord transection is associated with the development of detrusor external sphincter dyssynergia in cats. These findings indicate that the cat is a suitable model for the study of lower urinary tract dysfunction after spinal cord injury. Inhibition of reflex detrusor activity was achieved by activation of a sacral inhibitory pathway by electrical stimulation of the sacral roots or anal sphincter in normal and spinal—injured animals, indicating presence of a sacral inhibitory pathway.

Detrusor-External Sphincter Dyssynergia

Detrusor-external sphincter dyssynergia is characterized by involuntary contractions of the external urethral sphincter during detrusor contractions. A review of 550 consecutive patients who underwent urodynamic evaluation revealed that this condition was found only in patients who had involuntary detrusor contractions owing to well defined neurologic lesions of the suprasacral spinal cord. All patients with supracervical neurologic lesions had synergistic voiding patterns. We conclude that bladder-external sphincter dyssynergia is a neurologic condition owing to interruption of the spinal pathways connecting the pontine mesencephalic and the sacral micturition centers. In the absence of such a neurologic lesion one should be extremely cautious in making this diagnosis.

Detrusor-external Sphincter Dyssynergia: A Detailed Electromyographic Study

We reviewed 54 cases of detrusor-external sphincter dyssynergia following complete urodynamic evaluations. All patients had well defined neurologic lesions of the suprasacral spinal cord. On the basis of urodynamic findings 3 types of dyssynergia were encountered: type 1 (30 per cent) was characterized by a crescendo increase in electromyographic activity that reached a maximum at the peak of the detrusor contraction, type 2 (15 per cent) consisted of clonic sphincter contractions interspersed throughout the detrusor contraction and type 3 (55 per cent) was characterized by a sustained sphincter contraction that coincided with the detrusor contraction. There was no correlation between the clinical neurologic level and the type of dyssynergia.

A Double-Blind Trial with the Antispasticity Drug Lioresal® in 15 Paraplegics with Upper Neuron Lesions

A double-blind placebo trial was taken with Lioresal, an antispasticity drug acting on the spinal cord level. The drug produced improvement of voiding function in 10 paraplegics with upper motor neuron lesions and detrusor external sphincter dyssynergia.