Urinary System Garmian University

Perioperative Block College of Medicine

2023 – 2024

The neuropathic lower urinary tract

Clinical consequences of storage and emptying problems
Neuropathic patients experience two broad categories of problems—bladder filling
and emptying— depending on the balance between bladder and sphincter
pressures during filling and emptying. The effects of these bladder filling and
emptying problems include incontinence, retention, recurrent UTIs, and renal
failure.

High- pressure sphincter

High- pressure bladder
If the bladder is overactive (detrusor hyperactive DH) or poorly compliant, bladder
pressures during filling are high; the kidneys have to function against these
chronically high pressures. Hydronephrosis develops, and ultimately, the kidneys
fail (renal failure). At times, the bladder pressure overcomes the sphincter pressure
and the patient leaks urine (incontinence). If the sphincter pressure is higher than
the bladder pressure during voiding (detrusor sphincter dyssynergia DSD), bladder
emptying is inefficient (retention, recurrent UTIs).
Low- pressure bladder
If the bladder is underactive (detrusor areflexia), pressure during filling is low. The
bladder simply fills up— it is unable to generate enough pressure to empty
(retention, recurrent UTIs). Urine leaks at times if the bladder pressure becomes
higher than the sphincter pressure (incontinence), but this may occur only at very
high bladder volumes or not at all.

Low- pressure sphincter

High- pressure bladder
If the detrusor is hyperreflexic or poorly compliant, the bladder will only be able to
hold low volumes of urine before leaking (incontinence)

Low- pressure bladder

If the detrusor is areflexic, such that it cannot develop high pressures, the patient
may be dry for much of the time. They may, however, leak urine (incontinence)
when abdominal pressure rises (e.g. when coughing, rising from a seated position,
or when transferring to or from a wheelchair). Their low bladder pressure may
compromise bladder emptying (recurrent U TIs).

Dr. Hewa M Penjweni

M.B.Ch.B F.I.B.M.S (urology) F.MAS (Urology)
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Bladder management techniques for the neuropathic patient
A variety of techniques and procedures are used to treat retention, incontinence,
recurrent UTIs, and hydronephrosis in the patient with a neuropathic bladder. Each
of the techniques described here can be used for a variety of clinical problems.
Thus, a patient with a high- pressure, hyperreflexic bladder that is causing
incontinence can be managed with an intermittent self catheterisation ISC (with
intravesical BTX injections, if necessary) or a Suprapubic cystostomy SPC or by
sphincterotomy with condom sheath drainage or by deafferentation combined with
a sacral anterior root stimulator (SARS).
Precisely which option to choose will depend on the individual patient’s clinical
problem, their hand function, their lifestyle, and other ‘personal’ factors such as
body image, sexual function, etc. Some patients will opt for an SPC as a simple,
generally safe, generally very convenient, and effective form of bladder drainage.
Others wish to be free of external appliances and devices because of an
understandable desire to look and ‘feel’ normal. They might opt for deafferentation
with a SARS.

Intermittent self- catheterization

Requires adequate hand function; the technique is a ‘clean’ one (simple hand
washing prior to catheterization), rather than ‘sterile’. Gel- coated catheters
become slippery when in contact with water, so providing lubrication. Usually done
3- to 4- hourly
Problems
 Recurrent UTIs
 Recurrent incontinence: check technique (adequate drainage of last few drops of
urine). Suggest increasing frequency of ISC to minimize the volume of urine in
the bladder (reduces bacterial colonization and minimizes bladder pressure). If
incontinence persists, consider intravesical BTX.
Indwelling catheters
Some patients prefer the convenience of a long- term catheter. Others regard it as a
last resort when other methods of bladder drainage have failed. The suprapubic
route (SPC) is preferred over the urethral route because of pressure necrosis of the
ventral surface of the distal penile urethra in men (acquired hypospadias—
‘kippering’ of the penis) and pressure necrosis of the bladder neck in women which
becomes wider and wider until urine leaks around the catheter (‘patulous’ urethra)
or frequent expulsion of the catheter occurs with the balloon inflated.
Problems and complications of long- term catheters
• Recurrent UTIs: colonization with bacteria provides a potential source of
recurrent infection.

Dr. Hewa M Penjweni

M.B.Ch.B F.I.B.M.S (urology) F.MAS (Urology)
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• Catheter blockages are common: due to encrustation of the lumen of the
catheter with bacterial biofilms. Proteus mirabilis, Morganella, and Providencia
species secrete a polysaccharide matrix. Within this, urease producing bacteria
generate ammonia from nitrogen in urine, raising urine pH and precipitating
magnesium and calcium phosphate crystals.
The matrix– crystal complex blocks the catheter.
Catheter blockage causes bypassing which soils the patient’s clothes. Bladder
distension can cause autonomic dysreflexia, leading to extreme rises in BP which
can cause stroke and death! Regular bladder washouts and increase catheter size
sometimes help. Impregnations of catheters with antibacterials (e.g. triclosan) are
under investigation. Intermittent filling and emptying of the bladder using a ‘flip-
flow’ valve may reduce the frequency of catheter blockages.
External sphincterotomy
Deliberate division of the external sphincter to convert the high- pressure, poorly
emptying bladder due to DSD to a low- pressure, efficiently emptying bladder
Indications: retention, recurrent UTIs, hydronephrosis.
Techniques
• Surgical (with an electrically heated ‘knife’ or laser).
Disadvantages: irreversible, post- operative bleeding, septicaemia, and stricture
formation.
• Intra- sphincteric BTX (botulinum toxin). A minimally invasive and reversible
alternative to surgical sphincterotomy;
Disadvantage: repeat injection required every 6– 12 months
• A third potential option is an oral or sublingual NO donor (e.g. nifedipine, GTN).
NO is a neurotransmitter which relaxes the external sphincter. Hypothesized as
a treatment for DSD

Augmentation
Technique of increasing bladder volume to lower pressure by implanting
detubularized small bowel into the bivalved bladder (‘clam’ ileocystoplasty) or by
removing a disc of muscle from the dome of the bladder (auto- augmentation or
detrusor myectomy). In the BTX era, augmentation is becoming less and less
frequently used because repeat (every 6– 12 months) BTX injections are often all
that is required to achieve an acceptable level of continence, but also because of the
short- and long term morbidity of augmentation (bladder stones in 15%, bladder
perforation, high- grade invasive bladder cancers).
Indications: incontinence unacceptable to the patient or hydronephrosis despite full
conservative therapy (regular ISC combined with anticholinergics and a trial of
bladder BTX injections).

Dr. Hewa M Penjweni

M.B.Ch.B F.I.B.M.S (urology) F.MAS (Urology)
3
Detrusor sphincter dyssynergia= DSD
 Deafferentation
Division of the dorsal spinal nerve roots of S2– 4 to convert the hyperreflexic, high-
pressure bladder into an areflexic, low- pressure one.
Can be used where the hyperreflexic bladder is the cause of incontinence or
hydronephrosis
Bladder emptying can subsequently be achieved by ISC or implantation of a nerve
stimulator placed on the ventral roots (efferent nerves) of S2– 4 to ‘drive’
micturition when the patient wants to void (a pager- sized externally applied
radiotransmitter activates micturition. Also useful for DSD/ incomplete bladder
emptying causing recurrent UTIs and retention

Intravesical botlinum toxin injections

Recently, intravesical BTX- A injections at multiple sites in the bladder every 6– 12
months have produced impressive reductions in bladder pressure and increases in
volume (bladder capacity), with a low risk of side effects.
As a consequence, surgical augmentation is nowadays only rarely done, being
reserved for cases where BTX has failed to work (where the patient is still wet
between passing ISC catheters or where there is persistent hydronephrosis).
BTX is a potent neurotoxin produced by the Gram- negative anaerobic bacterium
Clostridium botulinum. Of the seven serotypes, only types A (BoNT- A) (‘Botox®’,
Allergan, CA, USA; ‘Dysport®’, Ipsen, Slough, UK) and B (‘Myobloc®’, Elan
Pharmaceuticals, NJ, USA) are used clinically.

Dyssynergia [dis″sin-ur´je-ә] [dys- + synergia]: disturbance of muscular coordination. See also asynergy.

detrusor-sphincter dyssynergia: contraction of the sphincter muscle of the urethra at the same time the detrusor muscle
of the bladder is contracting, resulting in obstruction of normal urinary outflow; it may accompany detrusor hyperreflexia
or detrusor instability. Called also vesico-sphincter d.

Dr. Hewa M Penjweni

M.B.Ch.B F.I.B.M.S (urology) F.MAS (Urology)
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