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SCI Forum Report

 

Advances in Treatment of Urologic Conditions in the SCI Patient

Presented on November 14, 2006, by Elizabeth A. Miller, MD, Assistant Professor, Department of Urology, University of Washington. Read the summary report or watch the video from this page.

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Summary Report

ANATOMY & DIAGNOSIS

"The neuroanatomy of the lower urinary tract is extremely complex,” said Elizabeth Miller, MD UW Assistant Professor of Urology. It consists of a great many nerve roots that branch off the spinal cord and come together in a network of neural pathways that govern the coordinated system of urination.

“But urologists like to simplify things, because we’re essentially glorified plumbers,” Miller joked. At the most basic level, our urinary system is a simple cycle of storage and voiding (urinating). When the bladder becomes full, nerve endings in the bladder wall send a message to the brain via the spinal cord. To void, the brain sends a message back to the bladder to contract (squeeze) the detrusor muscles (the muscles that make up the bladder wall) and relax the sphincter (a muscle that opens and closes) to release urine. After SCI, the neural pathways controlling this cycle no longer function normally.

“The recurrent theme in neurourology is not only to enhance quality of life for the patient, but to minimize bladder infections and protect the kidneys,” Miller stated. “And actually, the most important thing is to protect the kidneys.”

A urologic evaluation of an SCI patient includes a neurologic exam of the genitourinary system, focusing on the lower abdomen and genitalia; urinalyses and urine cultures; serum creatinine test to see how well the kidneys are functioning; and ultrasound or CT imaging of the kidneys and bladder.

“I like to do some kind of imaging pretty regularly in the first couple of years after injury because people are more prone to develop kidney and bladder stones in those early years,” Miller noted. Once she knows the kidney and bladder are stable, she does imaging every year or two.

“One of the most important components of the neurourology exam is the multichannel video urodynamic study,” she continued. “It sounds fancy and mysterious but it’s actually fairly simple.” Bladder, abdominal, and external sphincter pressures and activity are measured during filling and emptying of the bladder. X-rays are taken of the bladder during the study. This test shows, on both EMG tracings and on video, the activity of the abdomen, detrusor (bladder muscle), and urethra during bladder emptying.

Miller insists that standard single channel urodynamic studies without video cannot accurately diagnose the SCI patient. “A neurogenic patient needs video and multichannel,” she asserted. “Otherwise you won’t get all the information you need.”

UROLOGIC CONDITIONS & INJURY LEVEL

Different kinds of injuries result in different kinds of urinary dysfunction, Miller said, “and even though there are multiple levels of injury, we can classify them into two categories.”

Suprasacral injuries

These include all injuries above the sacral level of the spinal cord (includes lumbar, thoracic and cervical lesions). Most individuals fall into this category, and the most common condition is an overactive bladder.

Sacral injuries

These are injuries that involve the lowest part of the spinal cord. These injuries usually result in underactivity of the bladder.

TREATMENTS

The management of neurogenic bladder problems will depend both on the diagnosis and on individual patient factors. For example, clean intermittent catheterization (CIC)— in which a catheter is inserted through the urethra into the bladder— is the preferred method for emptying the bladder in SCI patients, but individuals with limited upper extremity (arm and hand) function are often unable to do it themselves. CIC is also much harder for women to perform than men.

Treatments can be categorized by whether they address either a storage (holding urine) problem or a voiding (emptying urine) problem.

Storage problems

The bladder cannot store urine adequately, causing incontinence (leakage).

Detrusor hyperreflexia: the bladder muscle (detrusor) is contracting involuntarily, causing incontinence.

Urethral deficiency: the urethra is weak and cannot keep urine from leaking out.

Voiding problems

The patient cannot empty his or her bladder, causing increased bladder pressure and potential kidney damage.
Detrusor sphincter dyssynergia (DESD & DISD) and areflexia.

Frequent UTIs

References
1. Riccabona M, et al. Botulinum-A toxin injection into the detrusor: a safe alternative in the treatment of children with myelomeningocele with detrusor hyperreflexia. J Urol 2004 Feb;171 (2 Pt 1):845-8.
2. Chartier-Kastler EJ, et al. A urethral stent for the treatment of detrusor-striated sphincter dyssynergia. BJU Int. 2000 Jul;86(1):52-7.