and Apichana Kovindha2
(1)
University of Antwerp, Antwerp, Belgium
(2)
Rehabilitation Medicine, Chiang Mai University, Chiang Mai, Thailand
17.1 Case 1
Figures 17.1 and 17.2
Fig. 17.1
Pdet at start is +8 cm H2O. Little change in abdominal pressure. Pressure rises several time in Pves and Pdet. Urethral tracing shows strong changes in pressure (spasticity). Minimal leakage. Detrusor zero line is not correct: detrusor pressure should be calculated −8 cm H2O
Fig. 17.2
Cystogram during video-urodynamic test shows open bladder neck and inflow contrast medium in the posterior urethra. FO numbers give sequence pictures taken
17.1.1 History
A 18 years old man.
Operated for tumor pinealis, radiotherapy, development of tethered cord, neurosurgical procedure 6 months ago. Voiding with Valsalva was changed to CISC 2 months ago. Constipation. Problems of ejaculation and erection.
17.1.1.1 LUT Function Basic Data Set
Urinary tract impairment unrelated to spinal cord injury: No
Awareness of the need to empty the bladder: Rarely desire to void and very rarely sensation of urgency mostly with leakage of small amount of urine.
Bladder emptying: Straining (abdominal straining, Valsalva’s manoeuvre) 2 times a day, intermittent catheterization 2 times a day
Average number of voluntary bladder-emptyings per day during the last week: 4–5
Any involuntary urine leakage (incontinence) within the last three months: Yes
Collecting appliances for urinary incontinence: No
Any drugs for the urinary tract within the last year: Prophylaxis with nitrofurantoin daily
Surgical procedures on the urinary tract: No
Any change in urinary symptoms within the last year: Not applicable
17.1.2 Clinical Examination
Perineal sensation for touch: present
Cremaster reflex: + bilaterally
Anal sphincter tone: weak
No anal reflex, no bulbocavernosus reflex. No voluntary contraction of pelvic muscles.
17.1.3 Urodynamic Basic Data Set (see Fig. 17.1)
Bladder sensation during filling Radiography or Cystogram: Slight pressure sensation at higher filling grade
Detrusor function: Neurogenic detrusor overactivity
Compliance during filling cystometry: Low= 10.2 mL/cm H20
Urethral Function during voiding: Spasticity, detrusor sphincter dyssynergia (DSD) with relaxation during second contraction, 22 ml leakage
Maximum detrusor pressure: ______50____ cm H2O
Cystometric bladder capacity: ___391_____ mL
Post void residual volume:___369_____mL
17.1.4 Urinary Tract Imaging Basic Data Set (see Fig. 17.2)
Ultrasound of the urinary tract: Normal
X-ray of the urinary tract—Kidney Ureter Bladder: Normal (as seen in the first picture of the video-urodynamics, Fig. 7.2)
Renography: Not done
Bladder neck at rest: Open
Other findings: Image of trabeculated wall of bladder during filling. Contrast solution fills the posterior urethra from the start of filling indicating incompetent bladder neck
17.1.5 Other Diagnostic Tests
Cystoscopy: Bladder trabeculated, bladder neck widely open.
Electrodiagnostic tests: SSEP from penile stimulation shows no reproducible signals. EMG bulbocavernosus muscle shows denervation. Slow reflex latency of lumbosacral reflexes
Electrosensation bladder and urethra: High threshold but sensation is present
17.1.6 Management
Stop straining for voiding and perform CISC 4–5 per day. Antimuscarinic drug. UDT control in 4 months
17.2 Case 2
Figures 17.3 and 17.4
Fig. 17.3
Pdet at start is 0 cm H2O. Filling rate 30 ml/min. No change in Pabd during filling. Pdet and Pves rise quickly indicating low compliance. High pressure overactive contractions and DSD. Involuntary micturition with incomplete bladder emptying
Fig. 17.4
Small trabeculated bladder. Flow into urethra posterior during involuntary voiding. Possibility grade 1 reflex right side but only visible very shortly on video during contraction of the bladder. FO numbers give sequences pictures taken
17.2.1 History
A 20 years old man, road traffic accident one year ago. T4 paraplegia, AIS A
17.2.1.1 LUT Function Basic Data Set
Urinary tract impairment unrelated to spinal cord injury: No
Awareness of the need to empty the bladder: No
Bladder emptying: Intermittent self-catheterization
Average number of voluntary bladder emptying per day during the last week: 6
Any involuntary urine leakage (incontinence) within the last three months: Very frequent leakage
Collecting appliances for urinary incontinence: Condom catheter
Any drugs for the urinary tract within the last year: Antimuscarinic
Surgical procedures on the urinary tract: No
Any change in urinary symptoms within the last year: No, clear urine
Other: Bowel: laxative 3/week, very rarely fecal incontinence. Reflex erection. UTI, now under antibiotics. Clear urine.
17.2.2 Clinical Examination
Perineal sensation for touch: positive left side; cremateric reflex: positive both sides. Tone anal sphincter: normal; anal reflex: positive, bulbocaversosus reflex: positive even with spasticity running into left lower limb. Contraction of pelvic muscles and anal sphincter: absent
Small penile skin lesion from condom catheter
17.2.3 Urodynamic Basic Data Set (see Fig. 17.3)
Filling rate 30 ml/min
Bladder sensation during filling cystometry: Absent
Detrusor function: Detrusor overactivity at 50 ml bladder filling, high pressures, leakage.
Compliance during filling cystometry: 4 ml/cm H2O
Urethral Function: dyssynergic sphincter contraction during detrusor contraction
Maximum detrusor pressure: ___154______ cm H2O
Cystometric bladder capacity: ___60____ mL
Post void residual volume: _____50___mL
17.2.4 Urinary Tract Imaging Basic Data Set (see Fig. 17.4)
Ultrasound of the urinary tract: Stasis/dilatation in upper urinary tract, right side and left side
X-ray of the urinary tract—Kidney Ureter Bladder:Normal
Renography: Not done
Cystogram: Vesicoureteric reflux Right, closed bladder neck at rest
Video-urodynamic
Bladder neck during voiding: Normal
Vesicoureteric reflux: Absent
Striated urethral sphincter during voiding: Closed (dyssynergia)
Other findings: Small bladder, trabeculation, flow into urethra posterior during leakage. Possibility grade 1 reflex right side but only visible very shortly on video during contraction of the bladder.
Egg shell stones are often not visible on x-ray
17.2.5 Other Diagnostic Tests
Cystoscopy: Eggshell stones, trabeculation bladder wall
Electrosensation bladder and urethra: Perception of electrical current in bladder and urethra indicating passage through afferent nerve fibers towards the cortex
Special test: Ice water test 20 ml at 4 Celsius shows very strong contraction of bladder
17.2.6 Management
Lithotripsy of the stones.
Control urodynamic test after 3 weeks showed same high pressure contraction of the detrusor and dyssynergia. No UTI. Higher dose antimuscarinics and intermittent catheterization.
Result: No leakage, bladder capacity 250 ml. Compliance 12 ml/cm H2O. NDO. Botulinum toxin injection resulted in good capacity, low pressure bladder with normal compliance.
17.3 Case 3
Figures 17.5, 17.6, and 17.7
Fig. 17.5
Pdet at start is 0 cm H2O. Filling rate 30 ml/min. Low Pabd rises at the end of bladder filling. No Pdet rise during filling indicates normal compliance. Low pressure NDO and DSD at end filling. FD = first sensation. ND = normal desire to void
Fig. 17.6
Enlarged image of end of filling showing low pressure NDO and DSD
Fig. 17.7
During filling: normal image of bladder, bladder neck closed. No contrast in urethra. FO numbers = sequence pictures taken. Pictures not given in actual sequence
17.3.1 History
A 30 years old man, road traffic accident two years ago. C7 tetraplegia, AIS C
17.3.1.1 LUT Function Basic Data Set
Urinary tract impairment unrelated to spinal cord injury: No
Awareness of the need to empty the bladder: Yes when full
Bladder emptying: Intermittent self catheterization
Average number of voluntary bladder emptyings per day during the last week: 4
Any involuntary urine leakage (incontinence) within the last three months: Very frequent leakage which disappeared under higher dosage of antimuscarinic drugs
Collecting appliances for urinary incontinence: No
Any drugs for the urinary tract within the last year: Antimuscarinic drugs, Oxybutinine 3 × 5 mg and changed to tolterodine retard 1/day
Surgical procedures on the urinary tract: No
Any change in urinary symptoms within the last year: Yes, 4 months ago autonomic dysreflexia, smaller bladder capacity, leakage. Higher dosage of oxybutynin made symptoms disappear but because of severe xerostomia it was changed to, tolterodine retard.
Other: After accident orthopaedic surgery with spondylodesis, interbody cage C5-C6, corporectomy C7, osteosynthese plate C6-T-2. Postoperatively rhadbomyolysis.
17.3.2 Clinical Examination
Urine: macroscopic clear, perianal sensation for touch: positive; cremasteric reflex positive: both sides, anal sphincter tone: normal; anal reflex: positive, bulbo reflex: positive. Voluntary contraction of pelvic muscles and anal sphincter: absent.
17.3.3 Urodynamic Basic Data Set (see Figs. 17.5 and Fig. 17.6)
Filling rate 30 ml/min.
Bladder sensation during filling cystometry: Feels filling of bladder: first sensation at 488 ml, sensation of desire to void at 567 ml.
Detrusor function: Low pressure NDO at 499 ml. No leakage
Compliance during filling cystometry: No Pdet rise from start filling to start of overactive contraction
Urethral Function: DSD
Maximum detrusor pressure: ___5______ cm H2O
Cystometric bladder capacity: ___600____ mL
Post void residual volume: _____Not applicable, no voiding___
17.3.4 Urinary Tract Imaging Basic Data Set (see Fig. 17.7)
Ultrasound of the urinary tract: Normal
X-ray of the urinary tract – Kidney Ureter Bladder: Normal at start video-urodynamics
Renography: Not done
Cystogram: Normal
Voiding cystogram: No voiding
17.3.5 Other Diagnostic Tests
Cystoscopy: Not done
Electrosensation bladder and urethra: Higher threshold of perception of electrical current in bladder and urethra indicating passage through sensory nerve fibers towards the cortex
17.3.6 Management
CISC and antimuscarinics continued.
17.4 Case 4
Figures 17.8, 17.9, and 17.10
Fig. 17.8
Pdet at start is 0 cm H2O. Filling rate 30 ml/min. Limited Pdet rise during filling indicating normal compliance. Involuntary start of voiding with DSD at start of bladder contraction followed by relaxation of the sphincter. Problems with Qura tracing due to partial blockage of disc in flowmeter. Only the last curve represents uroflow
Fig. 17.9
Enlarged image of end of filling showing some pressure rise in Pabd. NDO with normal voiding pressure. DSD at start voiding only. Voiding with small residual. Technical problems with Qura tracing due to partial blockage of disc in uroflowmeter
Fig. 17.10
Plain X-ray from start is missing. FO numbers give sequence of pictures taken. Normal image of bladder, bladder neck closed during filling. Voiding with normal passage through the urethra. Small residual urine not depicted here
17.4.1 History
A 63 years old man, aortic dissection 1 year ago with paraplegia 9, AIS C
17.4.1.1 LUT Function Basic Data Set
Urinary tract impairment unrelated to spinal cord injury: No
Awareness of the need to empty the bladder: Yes
Bladder emptying: Voluntary voiding with high residual, involuntary voiding of large quantities, intermittent catheterization 3 times per week. Clear urine.
Average number of voluntary bladder-emptyings per day during the last week: 4
Any involuntary urine leakage (incontinence) within the last three months: very frequent leakage
Collecting appliances for urinary incontinence: Diaper
Any drugs for the urinary tract within the last year: No, but multiple drugs for blood pressure, kidney and heart
Surgical procedures on the urinary tract: No
Any change in urinary symptoms within the last year: No
Other: When aortic dissection happened he was urgently operated and a long period followed in critical care with priapism, fasciotomy left leg, hemodialysis during 3 weeks, suprapubic catheter, depression.
17.4.2 Clinical Examination
Perineal sensation for touch: absent; cremateric reflex: positive both sides. Tone anal sphincter: normal; anal reflex: positive, bulbocaversosus reflex: positive. Voluntary contraction pelvic muscles and anal sphincter: weak
17.4.3 Urodynamic Basic Data Set (see Figs. 17.8 and Fig. 17.9)
Filling rate 30 ml/min
Bladder sensation during filling cystometry: Sensation urgency at 193 ml
Detrusor function: Detrusor pressure 0 cm H2O at start. NDO at 199 ml
Compliance during filling cystometry: 3 cm H2O pressure rise from start to end filling (before NDO) = 199/3 = 66 ml/cm H2O
Urethral Function: Contractions at start bladder contraction but relaxation afterwards with voiding
Maximum detrusor pressure: ___28_____ cm H2O
Cystometric bladder capacity: ___199____ mL
Post void residual volume: _____20 ml
Uroflow: Qmax 10.7 ml/s, average flow rate 5.5 ml/s, flow time 18 s, voiding time 18 s, time to qmax 0 s___
17.4.4 Urinary Tract Imaging Basic Data Set (see Fig. 17.10)
Ultrasound of the urinary tract: Normal
X-ray of the urinary tract—Kidney Ureter Bladder: Normal at start videourodynamics (image not shown in Fig. 17.10)
Renography: Not done
Cystogram: Normal
Voiding cystogram: Normal
17.4.5 Other Diagnostic Tests
Cystoscopy: Not done
Electrosensation bladder and urethra: Perception of electrical current in bladder and urethra indicating passage through afferent nerve fibres to cortex, but higher threshold
Ice water test: Positive
17.4.6 Management
Teach CISC 4/day and start antimuscarinics. If leakage continues, increase dosage of antimuscarinics and cystoscopy to exclude local bladder pathology.
17.5 Case 5
Figures 17.11, 17.12, and 17.13
Fig. 17.11
Pdet at start is −4 cm H2O. Filling rate 30 ml/min. Slow pressure rises at end bladder filling, normal compliance. Abdominal pressure undulates at end of filling giving undulating in Pdet tracing. FD = first desire to void = heaviness in lower abdomen. Artifacts in flow line during first part of cystometry because blocking in uroflowmeter
Fig. 17.12
Enlarged image of end of filling showing some pressure rise in Pves and Pdet. Ondulations in Pabd
Fig. 17.13
Normal image of bladder. Bladder neck opens with some contrast solution leaking in the prostatic urethra. FO number gives sequence of pictures taken
17.5.1 History
A 32 years old man, 3 months ago fell from height with T11 paraplegia, AIS B
17.5.1.1 LUT Function Basic Data Set
Urinary tract impairment unrelated to spinal cord injury: No
Awareness of the need to empty the bladder: No
Bladder emptying: CISC 4 per day with clear urine
Average number of voluntary bladder-emptying per day during the last week: 4
Any involuntary urine leakage (incontinence) within the last three months: Regularly leakage when making transfers
Collecting appliances for urinary incontinence: Diaper
Any drugs for the urinary tract within the last year: No
Surgical procedures on the urinary tract: No
Any change in urinary symptoms within the last year: Not applicable
Other: No erection, no sensation of defecation, manual evacuation of stool
17.5.2 Clinical Examination
Urine: Macroscopical clear. Perineal sensation for touch: negative. Cremasteric reflex: negative both sides. Anal sphincter tone: open sphincter; anal reflex: negative, bulbocavernosus reflex: negative. Voluntary contraction of pelvic muscles and anal sphincter: not possible
17.5.3 Urodynamic Basic Data Set (see Figs. 17.11 and 17.12)
Filling rate 30 ml/min
Bladder sensation during filling cystometry: Sensation of some heaviness in pelvic region at 597 ml. Does not increase when further filled up to 651 ml.
Detrusor function: Detrusor pressure −4 cm H2O at start. Detrusor areflexia. Leakage when getting on the urodynamic table
Compliance during filling cystometry: 26 cm H2O pressure rise from start to end filling. Calculated compliance 25.2 ml/cm H2O
Urethral Function: Little change in pressure during filling. Pressure rises at end of filling.
Maximum detrusor pressure: ___16 + 4 = 20_____ cm H2O
Cystometric bladder capacity: ___651____ mL
Post void residual volume: _____651 ml
Uroflow: no flow.
17.5.4 Urinary Tract Imaging Basic Data Set (see Fig. 17.13)
Ultrasound of the urinary tract: Normal
X-ray of the urinary tract—Kidney Ureter Bladder: Normal at start of video-urodynamics (not depicted in Fig. 17.13)
Renography: Not done
Cystogram: Bladder neck opens at rest
Other findings: Normal bladder, with open bladder neck and inflow of contrast in proximal urethra during filling
Voiding cystogram: No voiding
17.5.5 Other Diagnostic Tests
Cystoscopy: Not done
Electrosensation bladder and urethra: Not done
17.5.6 Management
CISC.
Because of bothersome leakage implantation of artificial sphincter AS800 around bladder neck. Not completely dry but very much improved.
17.6 Case 6
Figures 17.14, 17.15, and 17.16
Fig. 17.14
Pdet at start = 0 cm H2O. Filling rate 30 ml/min. Low pressure rises at the end of bladder filling in Pves and Pdet. After filling stopped Pdet decreases. Pdet pressure rise between start and end of filling, normal compliance (474/30=16). FD = first desire to void. ND = normal desire to void
Fig. 17.15
Enlarged image of end of filling showing Pves and Pdet pressure rise. Pura high pressure with peaks. After stop filling gradually lowering of Pdet
Fig. 17.16
Normal image of bladder, bladder neck closed. FO number = sequence of pictures taken. Not all pictures depicted here
17.6.1 History
A 47 years old woman, road traffic accident 16 months ago, T8 paraplegia, AIS A
17.6.1.1 LUT Function Basic Data Set
Urinary tract impairment unrelated to spinal cord injury: No
Awareness of the need to empty the bladder: No
Bladder emptying: Suprapubic catheter because of body weight and personal choice, clear urine
Average number of voluntary bladder emptyings per day during the last week: Not applicable
Any involuntary urine leakage (incontinence) within the last three months: Rarely leakage beside catheter
Collecting appliances for urinary incontinence: Diaper
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