The various types of neurogenic bladder dysfunction: an update of current therapeutic concepts

Abstract

SummaryIncreased experience with treatment strategies developed during the last 10 years in the field of neurourology justifies an update of current therapeutic concepts. Based on a rather simple, but clinically useful, classification of detrusor-sphincter dysfunction the therapeutic concepts now available for four prototypes of detrusor-sphincter dysfunction are discussed.( 1) For the combination of a hyperreflexive detrusor with a hyperreflexive (spastic) sphincter, characteristic for the reflex-and the uninhibited neuropathic bladder, detrusor sphincter dyssynergia (DSD) is still the greatest problem, and transurethral sphincterotomy is the method of choice if this situation cannot otherwise be managed. One concept is to convert detrusor hyperreflexia into hyporeflexia by adequate pharmacotherapy, which is nowadays available, and to assist or to accomplish bladder emptying by clean intermittent (self-) catheterisation (GIG) with the advantage of dry intervals in between. Japanese colleagues recommend bladder overdistension during the spinal shock phase to achieve detrusor hyporeflexia, but this procedure is rather decisive at an early stage of the disability, leaving the detrusor no chance for further rehabilitation. Another possibility is rhizotomy of the sacral posterior roots to eliminate detrusor hyperreflexia, and the simultaneous implantation of a sacral anterior root stimulator (Brindley) to achieve electrically induced micturition. From our personal experience with 12 patients this concept is ideal for female patients with unbalanced reflex bladder and otherwise uncontrollable reflex incontinence.(2) The combination of a weak detrusor with a spastic sphincter is a clear indication for GIG, as the bladder is emptied regularly, and due to the spastic sphincter, the patient stays continent as long as controlled fluid intake prohibits overflow incontinence. The implantation of an anterior sacral root stimulator is an alternative approach provided that at least weak reflex detrusor contractions are present.(3) With the combination of an areflexive or hyporeflexive detrusor and a flaccid pelvic floor, passive voiding by abdominal straining or by the Grede manoeuvre is usually recommended, but should be replaced by GIG if this mechanism of bladder emptying creates unphysiological high and dangerous intravesical pressures, or if vesico uretero-renal reflux is present. Neurogenic urinary stress incontinence is usually associated with this type of lesion and can be successfully treated by the implantation of an artificial urinary sphincter (Scott). However in two thirds of the patients with neurof!enic bladder

Urinary incontinence in brain injury

“…Further studies are mandatory to establish whether the administration of anticholinergic drugs can shorten the duration of incontinence in this type of bladder hyperreflexia [17,18,19,20,21].…”

Lower Urinary Tract and Sexual Dysfunction in Neurological Patients

“…The patient in the upper right corner is at risk of developing upper urinary tract involvement. The graph was constructed using the Madersbacher classification [3]. …”

“…All different combinations of a normoactive, overactive or underactive detrusor with a normoactive, overactive or underactive urethral sphincter may be found in individual patients. This classification of LUTD was proposed by Madersbacher [3] and is clinically the most useful as it is directly applicable for planning rational treatment. Here, two common patterns of possible LUTD in two individual patients are shown, one demonstrating a combination of an underactive detrusor with a normoactive sphincter, the other an overactive detrusor with an overactive sphincter.…”

“…The European Association of Urology Guidelines on Neurogenic Lower Urinary Tract Dysfunction [2] recommends the simple and therapeutically oriented Madersbacher classification system [3] for clinical practice, which differentiates between the state of the detrusor (on one side) and that of the urethral sphincter (on the other side) as either under- or overactive (or normal; fig. 2).…”

Factores pronósticos del tratamiento endoscópico del reflujo vesicoureteral en pacientes con lesión medular

“…Madersbacher 107 presentó una clasificación muy sencilla, centrada fundamentalmente en las consecuencias terapéuticas .Se basa en el concepto clínico de que existe una diferenciación importante en el diagnóstico entre las situaciones de presión alta y baja del detrusor durante la fase de llenado y la relajación del esfínter uretral y la ausencia de relajación o DDEP (Disinergia Detrusor esfínter Periruetral), durante la fase de…”