FACT OR FICTION Jacob Golomb Department of Urology Chaim Sheba Medical Center Tel Hashomer NEUROGENIC UNDERACTIVE DETRUSOR Central completeincomplete Spinal cord injury trauma vasc ID: 845762
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1 THE “ACONTRACTILE” BLADDER -
THE “ACONTRACTILE” BLADDER - FACT OR FICTION? Jacob Golomb Department of Urology Chaim Sheba Medical Center Tel Hashomer NEUROGENIC UNDERACTIVE DETRUSOR
2 Central (complete/incomplete): •
Central (complete/incomplete): • Spinal cord injury - trauma, vascular, disc disease, spinal stenosis • Spinal cord disease - myelitis, tumor, MS, spina bifida •
3 Conus medullaris injury (cauda equina
Conus medullaris injury (cauda equina syndrome) NEUROGENIC UNDERACTIVE DETRUSOR (cont.) Peripheral - pelvic plexus injury: • Trauma • Infection (herpes zoster,
4 Guillain - Barre’ syndrome) • Pe
Guillain - Barre’ syndrome) • Pelvic tumor extending to nerves • Major pelvic ablative surgery (Miles operation, low anterior resection of rectum, radical hysterectomy)
5 Diabetic cystopathy: Decreased
Diabetic cystopathy: Decreased bladder sensation Increased capacity Impaired contractility • Permanent catheter drainage • Intermittent catheteri
6 zation • Sphincterotomy Trea
zation • Sphincterotomy Treatment of all entities aims at adequate bladder emptying and low - pressure storage TREATMENT OPTIONS FOR NEUROGENIC UNDERACTIVE DETRUSOR NON -
7 NEUROGENIC UNDERACTIVE DETRUSOR •
NEUROGENIC UNDERACTIVE DETRUSOR • DOIC ( D etrusor O veractivity with I mpaired C ontractility) • Psychogenic urinary retention • Long - standing bladder outlet obst
8 ruction • Aging • Idiopa
ruction • Aging • Idiopathic conditions “ICS Standard Urodynamic Test: Uroflowmetry and PVR plus transurethral cystometry and pressure - flow study , all performed in
9 the patient’s preferred or most us
the patient’s preferred or most usual position; usually comfortably seated and or standing if physically possible. The patient(s) may be then reported as having had an ICS standa
10 rd urodynamic test (ICS - SUT)’.”
rd urodynamic test (ICS - SUT)’.”. Peter F.W.M Rosier et al: International Continence Society Standard Good Urodynamic Practices and Terms 2015 . Urodynamics, Uroflowmetry,
11 Cystometry and Pressure - Flow Study .
Cystometry and Pressure - Flow Study . www.ics.org/Documents/DocumentsDownload.aspx?DocumentID= 3077 . Mis - interpretation of urodynamic graphs • D.A., 66 years old • 6
12 months ago AUR • Following weani
months ago AUR • Following weaning from indwelling catheter he voided only small volumes • US: trabeculated bladder, prostate 40 gram, PVR 750 cc • Urodynamics: Starte
13 d SIC + Betanechol Repeat Urodynamics
d SIC + Betanechol Repeat Urodynamics TURP L.Y., 64 years old Voiding difficulties for the past 10 years Was treated with alpha - blockers and betanechol without improvement On
14 SIC for the past 2 years, no spontane
SIC for the past 2 years, no spontaneous voiding US: trabeculated bladder, prostate 30 grams Urodynamics: Advised to continue SIC TURP W,I., 56 years old Has voiding diff
15 iculties for the past 30 years In 2
iculties for the past 30 years In 2007 underwent BNI with symptomatic improvement for several years US: normal bladder, prostate 40 grams Cystoscopy: interpreted as normal Urodyn
16 amics: Was started on SIC TURP •
amics: Was started on SIC TURP • Detrusor underactivity is defined by the International Continence Society (ICS) as ‘‘a contraction of reduced strength and/or duration, resul
17 ting in prolonged bladder emptying a
ting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span ’’ . Abrams P, Cardozo L, Fall M, et al. The standardisation o
18 f terminology of lower urinary tract fun
f terminology of lower urinary tract function: report from the Standardisation Sub - committee of the International Continence Society. Neurourol Urodyn 2002 ; 21 : 167 – 78 .
19 • However, the ICS report falls short
• However, the ICS report falls short in specifying parameters for reduced contraction strength , prolonged bladder emptying , or normal time span . • Suggested working definiti
20 on: “ The underactive bladder is a sy
on: “ The underactive bladder is a symptom complex , and is usually characterised by prolonged urination time with or without a sensation of incomplete bladder emptying , usual
21 ly with hesitancy , reduced sensatio
ly with hesitancy , reduced sensation on filling, and a slow stream ” . Chapple CR et al. The Underactive Bladder: A New Clinical Concept?. Eur Urol 68 ( 2015 ) 351 - 353 .
22 Based on a consensus group meeting at
Based on a consensus group meeting at the International Consultation on Incontinence – Research Society and ICS annual meetings in September and October 2014 . IN SUMMARY: • T
23 he urodynamic diagnosis of non - neuroge
he urodynamic diagnosis of non - neurogenic detrusor underactivity in men with LUTS needs to be based on strict criteria, which are not defined yet. • Permanent SIC should be applie
24 d in men with LUTS and urinary retent
d in men with LUTS and urinary retention with utmost prudence. • In non - neurogenic men with urinary retention, the options of TURP versus permanent SIC should be discussed with t