Neurogenic Bladder Obstruction

Fig. 9.1

Drainage into an external condom catheter

Fig. 9.2

Low pressure filling in a decompensated, hypocontractile bladder

Fig. 9.3

Abdominal leak point pressures

A multichannel videourodynamics (VUDS) was performed in the supine position. The condom catheter was carefully removed without any injury to his penile skin. Initial catheterization revealed a 400 cc residual bladder volume. A rectal catheter was placed for intra-abdominal pressure measurements. A separate 7-French dual-lumen catheter was placed in the bladder. Catheters were zeroed, and filling with Cysto-Conray was begun at 30 cc/min. The filling phase of the study revealed a compliant bladder with low filling pressures. He was able to leak with cough, with abdominal leak point pressures (ALPPs) measured at 60–75 cm H₂O. Initial continuous blood pressure monitoring revealed stable blood pressures ranging from 140/65 to 160/55. As he approached a bladder volume of 600 cc, he started to experience sweats and headache, and another check of his blood pressure revealed it was 180/85. Concerned he was developing AD, the volume infusion was halted.

Fluoroscopic images revealed the bladder neck was open, but his external sphincter did not open. There was no VUR at a volume of 600 mL. He was able to empty another 100 mL with strain. His bladder was then drained of 550 cc. His sweats and headache resolved. His blood pressure returned to 140/65.

Findings

The patient has normal compliance. Despite previous sphincterotomy, he has evidence of a bladder which has decompensated over time, with hypocontractility , and an external sphincter which does not open. The external sphincter dysfunction is characteristic of a neurological lesion causing lack of relaxation of the pelvic floor. He has no voluntary control over the external sphincter and is not able to completely empty his bladder, with residuals of urine of approximately 300–500 cc at a time. This incomplete emptying puts him at risk for recurrent infection. His AD manifests more frequently, secondary to bladder distension and even more so at times of symptomatic infection. Fortunately, his bladder decompensation and lack of sensation did not impact his upper tract .

9.2.1.5 Treatment Options

He is essentially allowing his bladder to currently empty through overflow incontinence. Management possibilities include the following: commit to intermittent catheterization at least three times a day (but this would require a dedicated caregiver, secondary to his poor dexterity), closure of the bladder neck and creation of an incontinent ileal chimney, another sphincterotomy, or placement of an indwelling catheter (urethral or suprapubic). Considering he is already managing his bladder with urinary leakage into an external condom catheter, he will likely be most effectively served with another sphincterotomy. For now, he has elected to think about his options further; his upper tracts have no evidence of hydronephrosis, renal function is appropriate, he has normal compliance, and there is no VUR . There is not an acute need for immediate action. While awaiting his decision, he will initiate methenamine hippurate 1 g by mouth twice daily, for UTI prophylaxis .

9.2.2 Patient 2

9.2.2.1 History

The patient is a 43-year-old gentleman with a history of MS, neurogenic bladder, incomplete emptying, and persistent urinary urgency, urge incontinence, and frequency, presenting to clinic for follow-up. He manages his bladder with a mix of self-void and self-catheterization, currently voiding every 1–2 h, with occasional urgency urinary incontinence, and catheterizing three times a day, per his report. He has three to four episodes of nocturia per night as well. He had initially tried oxybutynin (both immediate and extended release formulations) without significant improvement in his urinary symptoms. He saw a mild improvement in his urgency and frequency with the combination of tamsulosin 0.4 mg and fesoterodine fumarate 8 mg daily. He takes baclofen 10 mg by mouth twice daily to aid with baseline muscle spasms. He is treated for a UTI every 3–4 months. He denies gross hematuria.

He continues to have some trouble with memory and attention. He denies any changes with vision. He is taking 100 mg of amantadine daily. He continues disease-modifying therapy with glatiramer given subcutaneously three times a week. He continues to take vitamin D 5000 units daily, and his vitamin D level was recently checked by his primary care provider at his annual physical and is reportedly within normal limits. He continues to walk for exercise. Compared to a year ago, there is nothing that he could do then that he is unable to do now.

9.2.2.2 Physical Examination

Generally he is in no apparent distress when sitting up on the examination table. There is full 5/5 strength throughout. Deep tendon reflexes are symmetric and brisk. Sensation to light touch is intact in all dermatomes. Neck is supple. Trachea is midline. Skin is warm and dry. Abdomen is soft, nontender, and nondistended. His lower extremities are atrophied. Genitourinary exam reveals a circumcised phallus and intact glans and meatus. Testes are descended bilaterally, with no palpable masses. Digital rectal exam reveals intact tone, with a 50 g, smooth prostate .

9.2.2.3 Labwork/Other Studies

Post-void residual was not checked, as he catheterizes three times a day to empty his bladder. A urine analysis was not checked, secondary to his intermittent catheterization and his lack of symptoms of infection at time of evaluation in clinic. His most recent serum creatinine was 0.8 mg/dL and eGFR was >89 mL/min/1.73 m². Renal ultrasound found no hydronephrosis, obvious masses, or perinephric fluid collections. Cystoscopy did not reveal any intravesical abnormalities such as stones, tumors, or diverticula. MRI imaging of the brain, cervical spine, and thoracic spine documented numerous non-enhancing T2-hyperintense foci scattered throughout the cerebral white matter, posterior fossa, cervical spinal cord, and thoracic spinal cord. No enhancing lesions identified.