Detrusor Hyperreflexia In Patients Research Articles

Combined intravesical and oral oxybutynin chloride in adult patients with spinal cord injury

Objectives. Detrusor hyperreflexia with elevated storage pressures presents a major risk factor for renal damage in patients with neurogenic lower urinary tract dysfunction. If standard anticholinergic treatment is unsuccessful, surgical treatment must be considered. We evaluated the effects of intravesical oxybutynin treatment on detrusor hyperreflexia in patients in whom standard oral treatment had failed. Methods. Twenty-five patients (mean age 36.7 years) with storage pressures greater than 40 cm H 2O despite standard anticholinergic treatment received intravesical (15 mg three times daily) and oral oxybutynin chloride treatment. The follow-up evaluations included urodynamic testing, renal ultrasound, urine examination (urinalysis and urine culture), and evaluation of side effects. Results. The mean follow-up was 6 months. Intravesical treatment led to an increase in bladder storage volume from 349 to 420 mL. The mean maximum storage pressure was significantly reduced from 54 to 26.5 cm H 2O. Detrusor storage pressures returned to values less than 40 cm H 2O in 21 of 25 patients. Dysreflexia was treated successfully in 3 of 5 patients. No patient developed renal damage. No severe side effects or drug-related discontinuation of treatment were observed. Conclusions. Intravesical oxybutynin therapy seems to be a safe and effective treatment option for detrusor hyperreflexia in adults and avoids surgical treatment in most patients. Long-term observations concerning side effects, acceptance, and efficacy are needed.

Early Experience of Intravesical Capsaicin for Treatment of Detrusor Hyperreflexia in Patients with Spinal Cord Injury

Early Experience of Intravesical Capsaicin for Treatment of Detrusor Hyperreflexia in Patients with Spinal Cord Injury

Can persisting detrusor hyperreflexia be predicted after transurethral prostatectomy for benign prostatic hypertrophy?

Detrusor hyperreflexia (DH) is frequently found in patients with benign prostatic hypertrophy (BPH) and persists in 30-50% of patients after successful removal of bladder neck obstruction by transurethral prostatectomy (TUR-P) or surgical enucleation of the prostate. It would be beneficial for surgeons to be able to identify patients who are at risk of persistent post-operative urinary irritation symptoms and DH. Twenty-three patients who showed DH pre-operatively were included in this study. Of these 23 patients, four had neurogenic bladder because of previous cerebrovascular disease. The other 19 patients were considered to have DH because of BPH. These 19 patients were classified according to their cystometry chart patterns. Pattern 1 was the continual sporadic onset and offset of DH, pattern 2 was a single episode of DH at a bladder volume of <160 mL, and pattern 3 was a single DH episode at a bladder volume >160 mL. Preoperative single-photon emission computed tomography (SPECT) was performed on 14 patients. Cystometric findings at 3 to 6 months after surgery were compared with the pre-operative findings. Four of the six patients with pattern 2 (67%) and all patients with pattern 3 (100%) showed an absence of DH after surgery. In contrast, all five patients with pattern 1 and all four patients with neurogenic bladder showed persistent DH. Compared with pattern 3 patients, pattern 1 patients more frequently complained of urgency before surgery, and their symptoms and uroflowmetry parameters did not improve afterward. Among 14 patients who had pre-operative SPECT, all eight patients with low cerebral blood flow in the frontal region showed persisting DH. Conversely, all six patients with normal SPECT results showed no DH after surgery. When DH occurs repeatedly (pattern 1) or occurs at a bladder volume of <160 mL (pattern 2), there is a greater risk of post-operative irritation symptoms. Abnormal SPECT findings can also predict the post-operative persistence of DH. Combing these two pre-operative examinations allows us to predict better post-operative DH in patients with BPH.

Acupuncture on Clinical Symptoms and Urodynamic Measurements in Spinal-Cord- Injured Patients with Detrusor Hyperreflexia

Objectives: We investigated the possible use of acupuncture for the treatment of urinary incontinence caused by detrusor hyperreflexia in patients with chronic spinal cord injuries. Methods: A total of 13 patients (11 males, 2 females) suffering from urinary incontinence due to spinal cord injuries were treated by acupuncture, which was carried out with disposable stainless steel needles inserted into the bilateral BL-33 (Zhongliao) points on the skin of the third posterior sacral foramina. Urodynamic studies were also performed before acupuncture, immediately after the 1st acupuncture and 1 week after the 4th acupuncture. In 6 patients, these urodynamic studies were performed again 1 month after the 4th acupuncture. Results: No side effects were recognized throughout the treatment period. Of the 13 patients, incontinence disappeared in 2 (15%) and decreased to 50% or less compared to baseline in a further 6 (46%). Maximum cystometric bladder capacity increased significantly from 76.2 ± 62.3 to 148.1 ± 81.5 ml 1 week after the 4th acupuncture (p < 0.01). In the 6 patients in whom cystometry was repeated 1 month after the 4th acupuncture, bladder capacity decreased from 187.5 ± 90.4 ml 1 week after the 4th acupuncture to 128.3 ± 93.4 ml. Conclusion: In spinal cord injury patients acupuncture could represent another valuable therapeutic alternative to the treatment of urinary incontinence caused by detrusor hyperreflexia.

Acupuncture for urinary incontinence in patients with chronic spinal cord injury. A preliminary report

We investigated the possible use of acupuncture for the treatment of urinary incontinence caused by detrusor hyperflexia in patients with chronic spinal cord injury. A total of 8 male chronic spinal cord injured patients with urinary incontinence were treated by acupuncture. Their ages ranged from 20 to 33 years (mean 27). The level of lesion was cervical in 4 and thoracic in 4. Detrusor hyperreflexia with uninhibited bladder contraction was confirmed by urodynamic studies in all of them. Acupuncture was performed using a disposable stainless needle (0.3 mm in diameter, 60 mm in length), which was inserted into bilateral BL-33 (Zhongliao) points and was rotated manually for 10 minutes. The treatment was conducted every week for 4 weeks. Urodynamic studies were repeated, immediately after the beginning of and a week after the completion of the treatment. Urinary symptoms were also checked before and after the treatment. No side effects were recognized throughout the treatment period. Among 8 patients, incontinence was controlled completely in 3 (38%) and partially in 3 (38%). The average maximum cystometric bladder capacity increased significantly, from 42.3 +/- 37.9 ml to 148.1 +/- 101.2 ml by the treatment (p < 0.05), while the average maximum bladder pressure was not changed. These data suggest that acupuncture could be a promising alternative for conventional therapies for urinary incontinence caused by detrusor hyperreflexia in patients with chronic spinal cord injuries.

Short-term effect of pudendal nerve electrical stimulation on detrusor hyperreflexia in spinal cord injury patients: importance of current strength

Twenty patients with chronic suprasacral spinal cord injury presenting with detrusor hyperreflexia were examined. In a preliminary study in ten patients we investigated the reproducibility of bladder capacity through the repetition of three cystometries. The effect of electrical stimulation (ES) on detrusor hyperreflexia was then investigated in ten patients during three consecutive cystometries, the first one without ES (baseline) and the other two with continuous ES of the dorsal penile or clitoris nerve via surface electrodes. Parameters of stimulation were 5 Hz frequency, 0.50 msec pulse duration, and stimulation strength of 1 and 2 times the bulbocavernosus reflex threshold. No significant differences in bladder capacity were found between the three consecutive cystometries without ES (respectively 97.0 ml, 101.5 ml and 105.6 ml). A current at the bulbocavernosus threshold (mean 24.4 mA) failed to induce a significant increase in bladder capacity compared to baseline (173.0 ml vs 155.5 ml, P = 0.17) whereas a current of twice the bulbocavernosus threshold (mean 48.9 mA) was highly significant (318.5 ml vs 155.5 ml, P < 0.007). ES of twice the threshold resulted in perineal contraction in all of the patients, the threshold ES never did. Our results emphasise the decisive roles of perineal contraction and of current strength for achieving short-term bladder inhibition in spinal cord injury patients. The carry-over effect may also be dependent on the current strength. If so, maximal pudendal ES could represent an alternative procedure in the treatment of detrusor hyperreflexia in these patients.

The effect of intravesical Marcain instillation on hyperreflexic detrusor contractions.

Thirty-six patients with suprasacral spinal injury were treated with intravesical local anaesthetic instillation. Eighteen of 32 patients (56%) were converted from an 'ice water positive' hyperreflexic state to an 'ice water negative' state by bupivacaine hydrochloride. Four patients treated with lignocaine hydrochloride showed no benefit. Intravesical local anaesthetic instillation is suggested as a possible treatment for selected cases of detrusor hyperreflexia in patients on intermittent catheterisation.

Oxybutynin Versus Propantheline in Patients with Multiple Sclerosis and Detrusor Hyperreflexia

Hyperreflexia is the most common urological finding in patients with multiple sclerosis. A prospective randomized study was done to compare the effectiveness of 2 commonly used drugs, oxybutynin and propantheline. Of the 34 patients entered into the trial 19 were treated with oxybutynin and 15 with propantheline. The urological symptoms (frequency, nocturia, hesitancy, urgency and urge incontinence) were graded according to severity from 0 to 3. Patients with urinary infection were excluded. Urodynamic examination, consisting of cystometrography and electromyography, was performed in all patients before treatment. Both groups of patients had comparable neurological, urological and urodynamic status before treatment. In 4 patients (21 per cent) treated with oxybutynin and in 4 (27 per cent) treated with propantheline side effects were so severe that the treatment had to be discontinued. Symptomatic response to oxybutynin was good in 10 patients (67 per cent), fair in 2 (13 per cent) and poor in 3 (20 per cent). Propantheline produced good symptomatic results in 4 patients (36 per cent), fair in 1 (9 per cent) and poor in 6 (55 per cent). The mean increase in maximum cystometric capacity on cystometrography was significantly larger in the oxybutynin group than in the propantheline group (144 ± 115 versus 35 ± 101). Our results indicate that oxybutynin is more effective than propantheline in the treatment of detrusor hyperreflexia in patients with multiple sclerosis.

Detrusor hyperreflexia. A survey on its etiology and treatment.

Detrusor hyperreflexia (DH) is a frequently occurring condition. The symptomatology is characterized by frequency, urgency and urge incontinence. DH is defined as involuntary, uninhibited detrusor contractions. The physiology and pathophysiology of the micturition reflex is reviewed. The balance between cerebral stimulation and supraspinal inhibition is discussed. DH is caused by disturbances in this balance. Whereas increased afferent impulses to the central nervous system due to local disorders in bladder and/or urethra may produce DH, a neurological disorder affecting the inhibitory nervous pathways from cortical and subcortical centres always result in uninhibited detrusor contractions. DH was found in 25% of 2000 patients. In the majority of the patients the DH was caused by a neurological disorder. The incidence of DH in patients with enuresis, gynecological patients with urinary incontinence and/or genital prolapse and patients with benign prostatic hyperplasia (BPH) is reported. In 62% of the patients with BPH the DH was eliminated after adequate surgical treatment of the infravesical obstruction. By contrast, DH in women with genital prolapse and/or incontinence persisted despite operative treatment. In a retrospective investigation of 152 patients with DH, the cause of the DH was unknown in 32 patients (21%). A clinical neurological examination revealed no evidence of neurological disease in 45% of the 22 patients examined. Voiding symptoms were the only complaint in these patients as well as in 30-40% of the patients in the other groups mentioned. This calls for improved investigatory methods in the evaluation of the balance between stimulation and inhibition of the micturition reflex. The presence of uninhibited detrusor contractions in apparently healthy patients should indicate a neurological examination since DH may be the first sign of a neurological disorder. The micturition reflex is conducted through long, uninterrupted neurons with a marked central integration. Therefore cystometry may be used as a supplement to the clinical neurological examination in the early diagnosis of pyramidal or extrapyramidal central nervous system disorders.