Patterns and Prevalence of N-LUTDs in Suprapontine Lesions

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© Springer Nature Switzerland AG 2020
G. Lamberti et al. (eds.)Suprapontine Lesions and Neurogenic Pelvic DysfunctionsUrodynamics, Neurourology and Pelvic Floor Dysfunctions

4. Urodynamic Patterns and Prevalence of N-LUTDs in Suprapontine Lesions

Eugenia Fragalà1  

Department of Urology, Hospital G.B. Morgagni- L. Pierantoni of Forlí, Forlí-Cesena, Italy



Eugenia Fragalà


NLUTDSuprapontine lesionsUrodynamicUrinary incontinenceNDO

4.1 Introduction

The prevalence of NLUTD in SPL is quite uncertain due to the poor number of epidemiology studies and the heterogeneity of the populations studied. Again, few data are reported in literature stratifying and analyzing patients with SPL.

Several SPL can affect the lower urinary tract function and lead to several lower urinary tract symptoms (LUTS) which may onset acutely or gradually according to the type of injury whether traumatic or not, stable or progressive (Fig. 4.1).


Fig. 4.1

Neurological disease classification

4.2 Cerebrovascular Accident (Stroke)

Stroke incidence ranges from 41 to 316 per 100,000 persons per year [1]; between stroke survivors only 10% have no residual effects, whereas 40% have mild disability, 40% have significant disability, and 10% require nursing home care [2].

NLUTDs are considered as one of the most affecting factors on health-related quality of life in poststroke patients [3]. Prevalence of urological complaints after cerebrovascular accidents (CVAs) ranges from 11% to almost 80% [4].

Urinary incontinence is the most common sequela of stroke [2, 5]. Patients may also report nocturia (36–79%), frequency (17.5–36%), urgency (19–29%), difficulty in voiding (25%), straining (3.5%), and pain (2.5%) [68]. Of course, the symptom presentation depends on the stroke phase.

In the acute phase of CVAs patients often show urinary retention that can be a neural representation of brain infract (“cerebral shock”) and manifests as neurogenic detrusor underactivity (NDU) or a nonrelaxing/overactive pelvic floor function.

In the post-acute (chronic) phase of stroke, normal bladder function can return or impaired bladder function may evolve to a chronic and usually stable dysfunction, mainly manifested by frequency and urgency and urgency incontinence [2].

The presence of NLUTDs following stroke has been strongly associated with increased mortality rates, poor functional outcomes, and worse health-related quality of life [9].

4.3 Parkinsonian Syndrome

The “Parkinsonian syndrome” includes a number of various nosologic entities that are grouped together on the basis of their shared clinical features but are separated on the basis of their different pathologies [10]. It is the second prevalent neurodegenerative disease after the Alzheimer’s disease [11].

A simple classification system splits Parkinsonian syndrome into Parkinson’s disease (75–80%) and non-Parkinson’s disease (20% with the greatest prevalence of multiple system atrophy).

4.3.1 Parkinson’s Disease (PD)

About 70% of PD patients suffer from NLUTDs [12] which commonly worse with the progression of the neurological disease. A multinational survey of 545 patients with a mild PD showed that patients usually report nocturia (62%) and urgency with or without incontinence (56%) [13]; less common are instead the voiding symptoms such as hesitancy, straining to void, and poor urinary stream, especially in the initial stages of the disease. Post-void residuals are typically low [14]; nevertheless it is necessary to remember the possible coexistence of bladder outlet obstruction (BOO) due for instance to benign prostatic hyperplasia (BPH) in elderly PD patients.

NDO with preserved bladder sensation is the most common urodynamic finding in patients with PD which are described in 36–93% of all cases (Fig. 4.2) [12]. NDU or acontractile detrusor may also be found (0–48%). Some studies demonstrated the evolution of the bladder behavior from NDO to NDU accordingly to the disease progression [15]. Majority of studies have reported a sphincter bradykinesia suggesting that an impaired or a delayed relaxation of the striated sphincter might exist although it is not defined as a proper dyssynergia [14, 16, 17].


Fig. 4.2

Male 70 years old affected by PD. UD: detrusor overactivity, preserved bladder sensation

4.3.2 Multiple System Atrophy (MSA)

Almost all of the patients (up to 96%) having MSA report urinary symptoms [18]. The commonest urinary symptom which is also considered a clinical parameter differentiating MSA from PD patients is voiding difficulty (79%), followed by storage symptoms such as nocturia (74%), urgency (63%), incontinence (63%), frequency (45%), nocturnal enuresis (19%), and urinary retention (8%). Patients may also show a combination of these symptoms. Up to 50–60% of MSA patients develop LUTS either before or concomitantly with orthostatic symptoms or motor disorders [19].

Considering urodynamics, NDO can be observed in 33–100% of patients with MSA, whereas NDU may be reported in 60% (Fig. 4.3) [19]. A subgroup of patients with MSA may show NDO during storage and NDU during voiding phase. Since MSA affects multiple brain regions, even the pons and lower regions, also a true detrusor-sphincter dyssynergia (DSD) is described in 47% of MSA patients [20, 21]; moreover 46–100% of MSA patients may show open bladder neck reflecting the intrinsic sphincter deficiency with urinary incontinence [20]. Uninhibited relaxation of the external sphincter may also be occasionally found during the filling phase and results in exacerbation of urinary incontinence.


Fig. 4.3

Female 64 years old affected by MSA. UD: detrusor overactivity and detrusor hypocontractility

4.4 Dementia

Dementia is a general term to describe a decline in mental ability which interferes with daily life; it affects 6.4% of adults over 65 years [22].

Alzheimer’s disease (AD) is the most prevalent irreversible cause of dementia (around 60–80% of cases).

LUTS may occur especially in the later phases of illness. Urinary incontinence is the most frequent symptom with a prevalence rate of 11–90% [23], although its etiology seems to be not only secondary to the underlying neurological illness, but also multifactorial including cognitive and physical disabilities, impaired conscious willingness, comorbidities, and surrounding environment.

4.5 Brain Tumors

Intracranial tumor incidence rate is about 10.82 per 100,000 individuals [24].

Brain tumors impair central voiding regulation. Urinary incontinence is the most frequent symptom and occurs in frontal located brain tumors and it is part of the frontal syndrome. Tumors in the frontal lobe may cause a loss of the central inhibitory output and lead to detrusor overactivity with urge incontinence. Voluntary control of voiding may also be impaired.

The incidence of LUTS among patients with frontal lobe tumors has been estimated as 14–28% [25].

Patients typically report storage symptoms like urgency, frequency, nocturia, and incontinence but symptom presentation can vary. Patients with pontine tumors are more likely to have voiding difficulties and retention.

Data on urodynamic findings in patients with intracranial tumors are scant and limited to single studies or case reports.

4.6 Cerebral Palsy

Cerebral palsy ranges from 3.1 to 3.6/1000 in children aged 8 years [26].

Approximately of 55.5% of subjects with CP experience one or more LUTS [27]. Urinary incontinence is the most frequent symptom with a prevalence ranging between 20 and 94%. Urgency and frequency are also reported in 38.5% and 22.5% of patients, respectively. Voiding symptoms are less prevalent than storage problems. Prevalence rate of hesitancy varies between 2 and 51.5%, with an average of 24%.

NDO is the commonest urodynamic observation, with a mean prevalence rate of 59% although more than 44% of CP patients having NDO do not report LUTS [28, 29]. About 70% of subjects with CP also show a reduced bladder capacity compared to the expected bladder capacity for age. Interestingly, some studies report DSD in 11% [27]. As CP definition includes only suprapontine insult, this peculiar finding may be explained in some patients as a concomitant unrevealed spinal lesion. Another theory stresses that investigated DSD is indeed a pseudo-DSD resulting from pelvic floor overactivity as a voluntary reaction to bladder overactivity.

4.7 Head Injury

Traumatic brain injuries affect suprapontine structures, often leading to NDO. Studies suggest that NDO is prevalently associated with right-side damage [30, 31], whereas left hemispheric injury is linked to impaired contractility [32]. Frontal lobe injuries determine NLUTDs more than injuries of other lobes [33, 34]; unilateral right cortical lesions in the prefrontal area produce temporary dysfunction; instead bilateral lesions are inclined to provoke permanent and chronic NLUTDs [35].

In the acute phase of traumatic brain injury spontaneous micturition is possible with persistent perception of bladder fullness; in mild stages [36, 37], voiding function is synergistic, with no pathological post-void residual (PVR). However, in up to 10% of acute patients, retention may be observed and the exact mechanism of this dysfunction has not been well investigated [38].

In post-acute phase, patients mainly report frequency, urgency, and urgency incontinence.

Symptom severity is usually in line with the extent of the injury [33]. PVR is not pathologic as a result of involuntary detrusor contractions [31].

Finally, NDO and a normal external sphincter function are the urodynamic patterns most frequently observed [39], although in some cases a reduced detrusor compliance has been described [33].

4.8 Conclusion

The wideness of the different SPL compromising distinct anatomic structure involved in the micturition control, the different types of neurological evolution during time (acute, chronic, progressive SPL), the possible presence of concomitant comorbidities due to the age of this population, or the presence of secondary neurological factors such as cognitive impairments are still the greatest challenges of knowledge which may amplify the clinical and urodynamic pitfalls in the diagnosis of NLUTDs in these subjects. Future research in neuro-urology should dedicate more interest to reduce this gap and help all clinicians to ameliorate continence care in SPL patients.

Mar 23, 2021 | Posted by in ABDOMINAL MEDICINE | Comments Off on Patterns and Prevalence of N-LUTDs in Suprapontine Lesions

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