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Neurological conditions

Supraspinal conditions / diseases above the brainstem

Stroke / CVA

  • Ischaemia or infarction of an area of the brain, typically due to thrombosis, occlusion and haemorrhage
  • Typically older patients who may have pre-existing lower urinary tract issues
  • High rates of urinary incontinence post stroke – although usually the sphincters are synergic
  • May be a period of acute “cerebral shock” after major stroke, with urinary retention requiring catheterisation for a period
  • Older patient who may be on medications with anticholinergic properties already
  • Most common long lasting urinary issue is phasic detrusor overactivity with overactive bladder

 

Dementia

  • Atrophy of loss of grey and white matter of the brain, resulting in deficits with memory and intellectual tasks
  • Incontinence is the main urinary manifestation which is multifactorial:
    • Disinhibition and loss of awareness of appropriate voluntary sphincter control
    • Concomitant ageing related disease – OAB, BOO
    • High rates of bacteriuria and infections, particularly in those institutionalised

 

Normal pressure hydrocephalus

  • Neurological condition characterised by progressive dementia, ataxia and urinary incontinence
  • Urinary incontinence is due to detrusor overactivity, with preservation of sphincteric synergy

 

Parkinson’s disease

Neurodegenerative disorder affecting dopaminergic neurons of the brain, particularly the substantia nigra, resulting in dopamine deficiency

  • Classic motor symptoms of parkinsonism – tremor, skeletal rigidity, and bradykinesia
  • 35 – 70 % of PD patients have urological dysfunction
  • May be exacerbated by pre-existing urological conditions and poor mobility
  • Most common symptoms are nocturia, frequency and urgency and the most common urodynamic finding is detrusor overactivity
    • Theorised that basal ganglia normally has inhibitory effect of micturition reflex, and the basal ganglia function is diminished in PD
  • Pseudodyssynergia is often seen – a result of sphincteric bradykinesia and delayed sphincter relaxation
  • Smooth sphincter is usually synergic

Classically, TURP was contraindicated in PD due to the finding of significant incontinence thought to due to acontractility of the striated sphincter – but many of these patients in historic studies probably had MSA rather than PD.

  • May still proceed with TURP if required, but consider UDS prior and counsel that outcomes may be less than expected in other cases

Typical treatments for detrusor overactivity can be effective including botox.

  • Hand function and tremor may limit ability to self catheterise
  • Deep brain stimulation may help bladder capacity

 

 

Multiple system atrophy (MSA)

  • Progressive neurodegenerative disease with widespread cell loss and gliosis
  • Affects the basal ganglia which causes parkinsonism, but also significant cerebral and autonomic symptoms also
  • Favoured diagnosis over Parkinson’s if urinary symptoms precede other signs of parkinsonism, urinary incontinence, high post void residual volumes, initial erectile dysfunction and abnormal EMG findings on urodynamics
  • Usual symptoms are urgency, frequency and nocturia, and predate other neurological symptoms by a few years
  • More likely to have issues such as sphincteric dysfunction and sphincteric denervation as well as poor compliance
    • Bad outcomes from TURP with incontinence expected
    • Open bladder neck at rest on fluoro, in absence of previous bladder neck surgery, is concerning for MSA
  • May also have difficulty initiating and maintaining voiding – pons and pontine micturition centre may be involved
  • Treatment difficult due to concomitant overactivity, sphincteric weakness and difficulty voiding – plus inability to self catheterise

 

Disease affecting the spinal cord

Multiple sclerosis

Characterised by neural demyelination in the brain and spinal cord, which is likely autoimmune related, with lesions known as plaques scattered through the nervous system causing various neurological abnormalities

  • Primarily diagnosed in adults aged 20 – 50, with women affected 2:1
  • Common presenting symptoms include optic neuritis, hyperreflexia, thermosensitivity, ataxia, bowel dysfunction, neurogenic bladder and sexual dysfunction
    • 10 – 15 % of MS presenting symptoms is urinary dysfunction
  • Cervical spinal cord most commonly affected location on imaging
  • May be a progressive disease, hence evolution of urinary symptoms over time
  • 50 – 90 % have some urinary symptoms, with incontinence in 30 – 70 % of patients
  • Frequency and urgency most common symptoms
  • Detrusor overactivity most common urodynamic finding (> 60 %)
  • DSD is common (25 % of patients)
    • Sensation generally intact, so beware pseudodyssynergia during detrusor contractions in filling
  • Impaired detrusor contraction can be seen in about 20 – 30 % also
  • Proactive management of overactivity can prevent most complications
  • Try to avoid irreversible treatments because MS can be relapsing and remitting and improve or progress
  • Despite similar urodynamic findings, upper tracts are much less commonly affected cf. spinal cord injuries
  • Normal overactive bladder treatments are useful – potentially higher rates of needing to self catheterise in MS patients (presumably due to concomitant underactive detrusor)

Acute transverse myelitis

  • Rapidly developing condition with motor, sensory and sphincteric abnormalities, usually with a well defined upper sensory limit
  • Several aetiologies – i.e., autoimmune, inflammatory, viral
  • Usually stabilises after 2 – 4 weeks without progression, but recovery is variable
  • Variable symptoms which may correlate to level of neurological symptoms but may not
  • May have a period of spinal shock like condition, or upfront detrusor overactivity +/- dyssynergia.

 

Spinal dysraphism / spina bifida

  • Can present with variable urinary symptoms – may be suprasacral (detrusor overactivity with DSD) or sacral (areflexic hypotonic) type symptoms – not always concordant with level of bony abnormality
    • “Classically” an areflexic bladder with open bladder neck and fixed external sphincter, with leakage occurring when bladder pressure exceeds resting fixed sphincteric pressure, plus SUI with abdominal pressure
    • Many however will have DSD and detrusor overactivity
  • Childhood management is key to preventing long term complications

 

Tethered cord syndrome is a stretch-induced functional disorder of the spinal cord with its caudal part anchored by inelastic structures – e.g. scar from previous surgery, fibrous structures, tumours

  • Classically manifests during growth spurts, or in adults with sports or stretching
  • Presents with back pain, lower limb neurological changes, or bowel or bladder dysfunction
  • May occur in 3 – 15 % of patients with myelomeningocele
  • No typical pattern of urinary dysfunction – be guided by urodynamics
  • Usually benefits from surgical release

 

Diseases distal to the spinal cord

Disc disease

  • Usually intervertebral discs prolapse posterolaterally and don’t affect cauda equina, but in 1 – 15 % of cases central disc prolapse occurs
  • Recall the spinal cord proper terminates and cauda equina begins posterior to L1 / L2 vertebrae
  • Most disc protrusions occur at vertebral levels L4/L5 and L5/S1
  • Urologically may manifest as areflexic detrusor / underactive bladder, but urodynamics often normal

Cauda equina syndrome – loss of perineal sensation with loss of voluntary control of anal and urinary sphincters – occurring due to any diseases affecting spinal canal

 

Pelvic surgery

Inferior hypogastric (pelvic) plexus lies on the lateral side of the rectum (and vagina) and gives off cavernosal nerves as well as parasympathetic and sympathetic nerves to bladder and sphincters.

  • Common to have urinary dysfunction after APR and radical hysterectomy
  • May have persistent dysfunction in 15 – 20 %
  • May be compounded by radiation, or other peripheral neuropathies (diabetes, chemotherapy) and pre-existing lower tract dysfunction
  • Can also give sexual and erectile dysfunction
  • The pattern is usually impaired bladder contractility, and sometimes the smooth sphincter is fixed open and the striated sphincter fixed with a degree of DSD
    • Difficult voiding with inability to generate bladder contraction, but SUI from open bladder neck and fixed striated sphincter
    • May have decreased compliance
    • TURP is tempting but may worsen stress incontinence due to already impaired sphincter function
  • A lot of the time dysfunction will improve after 6 – 12 months – ISC preferable to manage during this time

 

Herpesvirus

  • Herpes zoster (shingles) may cause invasion of sacral dorsal root ganglia can produce urinary retention and detrusor areflexia – days to weeks after other viral manifestations
  • Retention can also occur due to genital HSV – due to pain or possible CNS involvement
  • Usually transient

 

Diabetes

  • Prevalence of diabetes induced urinary dysfunction difficult to quantify due to pre-existing and concomitant urinary conditions
  • Estimates vary 5 – 60 % of diabetics have some urinary dysfunction
  • Classic urodynamic findings of diabetic cystopathy:
    • Impaired bladder sensation
    • Increased cystometric bladder capacity
    • Poor flow
    • Increased residual volumes
  • Typically low pressure low flow voiding, compared to bladder outlet obstruction with high pressure low flow
  • Some patients will have detrusor overactivity as well