VOIDING DYSFUNCTION AND NEUROLOGIC DISORDERS

Chapter 14 VOIDING DYSFUNCTION AND NEUROLOGIC DISORDERS



Gary E. Lemack


Perhaps more than any other situation facing physicians who care for patients with bladder dysfunction, care of the neurologic patient requires a thorough initial investigation, frequently with upper and lower urinary tract evaluations in addition to periodic assessments to minimize the urologic morbidity often associated with these conditions. Development and refinement of urodynamic techniques to assess bladder function in patients with neurogenic voiding dysfunction have enhanced our understanding of their condition and improved our ability to identify when these patients require more intense monitoring and intervention. As new treatment strategies for these conditions have surfaced and as patients at risk for morbidity associated with neurogenic voiding dysfunction are recognized more promptly, the likelihood of finding advanced urologic dysfunction at the time of initial presentation is gradually decreasing. This chapter focuses on evaluation of patients with neurogenic voiding dysfunction and discusses specific aspects of some of the more common subgroups.



EVALUATION OF THE NEUROLOGIC PATIENT



Neurologic History


Establishing the onset of bladder and systemic symptoms in patients with progressive neurologic conditions (which often predate the diagnosis) and documenting recent changes in symptom severity are essential, because this information usually influences treatment recommendations. Disease duration has been correlated with the development of urinary symptoms, particularly in patients with multiple sclerosis or Parkinson’s disease.1 Even those with presumably fixed neurologic conditions (e.g., spinal cord injury, myelomeningocele) may have insidious but progressive symptomatic deterioration (e.g., from development of a syrinx or tethered cord), and therefore any recent changes in sensory or motor function should be directly assessed.


Patients with movement disorders should be carefully questioned about the onset of their neurologic symptoms compared with their urinary symptoms, because those with more progressive syndromes, such as multiple systems atrophy, often develop autonomic disturbances such as bladder and erectile dysfunction early during the course of their illness. Every attempt should be made to identify these patients because their overall response to surgical urologic interventions is poor.2 The Hoehn and Yahr stage should be documented in patients with Parkinson’s disease. This staging information can be useful in predicting the severity of bladder dysfunction and prospects for further deterioration.3


Patients with multiple sclerosis should be queried about the timing of the onset of symptoms and about recent exacerbations, because such exacerbations frequently are initiated by urologic events.4 Patients should be specifically questioned about the development of lower extremity motor dysfunction, because there is a strong correlation between pyramidal symptoms, such as weakness and spasticity, and bladder dysfunction in patients with multiple sclerosis.5 Symptoms of urge incontinence, urgency, and nocturia are strongly correlated with severe pyramidal dysfunction as measured by Kurtzke scores.6 Inquiring about the classification of their condition (e.g., relapsing remitting, primary progressive, secondary progressive) and the timing and findings of their most recent magnetic resonance imaging (MRI) studies may be important in planning therapy, particularly when considering surgical options, which may require considerable dexterity.


In patients with recent acute events, such as cerebrovascular accidents (CVAs), information about the stroke location and the recovery since the event is useful because stroke location im-pacts theprognosis.7 Specific questions regarding the presence of voiding disturbance and urinary leakage episodes before the stroke are required, because the persistence of new-onset urinary incontinence after stroke can indicate a poor overall prognosis and is a strong indicator of eventual functional dependence in patients after stroke.8


Patients with history of back surgery and intervertebral disk protrusion should be questioned about the vertebral level of the surgery or affected disk and about the presence of ongoing sensory deficit because patients with multiple operations or advanced disk prolapse may be at higher risk for voiding disturbances.9 Patients should also be evaluated for a diagnosis of cervical myelopathy, because these patients frequently have symptomatic bladder dysfunction that may be independent of the severity of other symptoms associated with this condition, such as spacticity.10


Current treatments should be documented, with particular attention to medications. Medications with properties that can affect the bladder outlet (typically those with α-agonist or α-antagonist properties) or detrusor contractility (typically those with anticholinergic properties) should be recorded, along with the use of narcotics and skeletal muscle relaxants. Diuretic use should also be documented. Altering the timing of diuretic intake may affect the severity of nocturia. Patients on diuretics and those with a history of congestive heart failure probably are not suitable candidates for treatment with vasopressin for nocturia and nocturnal enuresis.



Physical Examination



General Observations


Although most patients with neurologic impairment are followed elsewhere for the primary condition, certain aspects of the physical examination are essential to document when evaluating them urologically, particularly if surgical intervention is being considered. Patients should be assessed for ambulatory disturbances at the initial visit. The degree of physical dependence of the patient, particularly as it relates to the ability to void independently, may affect the frequency of leakage episodes. Self-catheterization of the urethra may be impossible in patients who are not ambulatory, particularly those with severe lower extremity spasticity or contractures.


Hand function in patients with cervical spinal cord injury, particularly the ability to grasp firmly between the thumb and index or middle finger, must be carefully judged in patients who may require intermittent catheterization after treatment. With the advent of single-system catheterization techniques, it is not mandatory that patients have bilateral hand function, although a careful assessment of the patient’s ability to work with such products is essential, particularly before considering surgery that will require clean intermittent catheterization postoperatively.


An evaluation of the skin, particularly in the gluteal region, should be carried out, because localized skin and subcutaneous infections and even more severe skin breakdown can occur in patients with restricted mobility. These issues need to be addressed before major reconstructive procedures are considered. Some patients may have intrathecal pumps in place, and their location and that of the tubing should be assessed before surgical endeavors.



Neurologic Examination


A brief neurologic examination is essential when first evaluating patients with presumed neurovesical dysfunction. Mental status should be assessed because significant cognitive dysfunction and memory disturbances have been independently associated with abnormal voiding function. An appreciation of past and current intellectual capacity may provide insight into the progression of lower urinary tract disorders and thereby guide the degree of complexity of treatment strategies. Motor strength and sensory level should be determined because distribution of motor and sensory disturbances can often predict lower urinary tract dysfunction, particularly in patients with multiple sclerosis.5


Cutaneous and motor reflexes require a thorough evaluation at the time of the initial encounter. The bulbocavernosus reflex, which is elicited by gently squeezing the glans penis in men or gentle compression of the clitoris against the pubis in women and simultaneously feeling for an anal sphincter contraction (by placing a finger in the rectum), assesses the integrity of the S2-S4 reflex arc. The anal reflex, which assesses integrity of S2 to S5, can be checked by applying a pinprick to the mucocutaneous junction of the anus and evaluating for anal sphincter contraction. The cremasteric reflex may be somewhat less reliable, but it assesses sensory dermatomes supplied by L1 to L2.


Muscle motor reflexes should be routinely evaluated. The most common of these are the biceps reflex (assesses C5 to C6), patellar reflex (L2 to L4), and Achilles (ankle) reflex (L5 to S2). Evidence of an upper motor neurologic injury includes spasticity of the involved skeletal muscle, heightened response to reflex testing, and an upgoing toe on gentle stroking of the plantar surface of the foot (i.e., positive Babinski’s sign).



Other Testing


A thorough investigation for upper tract abnormalities (imaging) and lower urinary tract dysfunction (video urodynamic testing) is mandatory when first evaluating patients with neurogenic voiding dysfunction and at periodic intervals thereafter. The frequency of testing is not readily agreed on, although many experts recommend annual upper tract evaluation (nuclear renal scan or renal ultrasound) and at least biannual urodynamic testing in high-risk patients (e.g., traumatic spinal cord injury).11 Others have advocated less frequent evaluations in stable patients.12 Regardless of the frequency of evaluations, the most important aspect of testing is to identify patients at risk for upper tract deterioration and to monitor them closely. Although a description of the technique of urodynamic testing is beyond the scope of this chapter, it is clear that in no other situation in urology is the importance of properly performed urodynamic testing as important as it is when evaluating the patient with neurogenic voiding dysfunction.



BLADDER DYSFUNCTION IN SPECIFIC NEUROLOGIC CONDITIONS



Traumatic Spinal Cord Injury



Suprasacral Injuries


The classification scheme most commonly used for patients with spinal cord injury is that developed by the American Spinal Injury Association (ASIA). Using this scheme, the level and completeness of the injury are assessed by careful examination of the affected dermatomes and muscle groups (Table 14-1

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Jun 4, 2016 | Posted by in ABDOMINAL MEDICINE | Comments Off on VOIDING DYSFUNCTION AND NEUROLOGIC DISORDERS

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