Detrusor sphincter dyssynergia (DSD)
ICS – incoordination between detrusor and sphincter during voiding due to neurological abnormality (synchronous contraction of detrusor and striated sphincter)
Involuntary contraction of the external sphincter, typically against a detrusor contraction, resulting in high bladder pressures.
High pressure voiding can compromise the upper tracts.
Urodynamic diagnosis:
- Saw toothed appearance on Pdet line
- Increased sphincteric activity on EMG whilst detrusor contraction
- Contrast hold up on fluoro at external sphincter (spinning top)
Management:
- ISC +/- botox or anti-cholinergics
- Long term catheter
- Sphincterotomy
- Urethral stent – causes incontinence, migration, pain etc
- Sphincteric botox
- SARS with dorsal rhizotomy – takes away reflex erections and can affect sensation/motor function if present
Hinman syndrome (non neurogenic neurogenic bladder, dysfunctional voiding)
Absence of neurological condition.
Failure to relax the pelvic floor (and often external sphincter) with same potential outcomes as neurogenic DSD.
Try aggressive pelvic floor therapy but ultimately may need ISC or long term catheterisation pending upper tract deterioration or complications.
Fowler syndrome
Syndrome of young women with failure of relaxation of the external urethral sphincter causing urinary retention, often associated with polycystic ovaries.
Characteristic complex repetitive discharges on EMG. Sphincteric complex may or may not become hypertrophic. Significant raised MUCP.
Clinical features:
- Classically second to fourth decade
- Most have a triggering event, often gynaecological surgery or other surgery
- Many have ovarian cysts, although relevance is unclear
- History of obstructive type urinary symptoms
- Mean bladder volume 1.2 L at diagnosis, characterised by suprapubic pain rather than urgency to void
- Associated with opioid use in up to 40 % of women presenting / diagnosed with Fowler
Urodynamics in Fowler’s:
- Delayed sensation during filling / large cystometric capacity
- Often unable to void – poor flow but low pressures also (cf. primary obstruction w high pressure)
- Narrowing at mid urethra/EUS on fluoro
Bladder neck dysfunction
Incomplete opening of the bladder neck / smooth muscle sphincter during voiding.
Classically younger or middle aged men with normal prostate volumes and unobstructed outlet on cystoscopy.
Obstruction demonstrable on urodynamics (high pressure low flow) with confirmed to be bladder neck on video urodynamics (or assumed in the absence of stricture and prostatic obstruction).
Treat with alpha blockers or bladder neck incision.