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DETRUSOR SPHINCTER 
GAURAV NAHAR 
DNB UROLOGY(STD. ) 
MMHRC 
DYSSYNERGIA
INTRODUCTION 
MICTURITION CYCLE: 
 Micturition cycle involves two relatively discrete 
processes: 
1. bladder filling and...
Bladder filling and urine storage : 
 Accommodation of increasing volumes of urine at a 
low intravesical pressure (norma...
Bladder emptying/voiding : 
 A coordinated contraction of bladder smooth 
musculature of adequate magnitude and duration....
NEURAL CONTROL OF THE LOWER URINARY 
TRACT 
 Peripheral Nervous System: The lower urinary tract is 
innervated by 3 sets ...
Mechanism of storage and voiding reflexes 
A) Storage reflexes. 
 During urine storage, distention of bladder 
produces l...
B) Voiding reflexes. 
 At the initiation of micturition, intense vesical 
afferent activity activates brainstem micturiti...
Smooth sphincter : 
 Smooth musculature of the bladder neck and 
proximal urethra. 
 A physiologic (but not anatomic )sp...
Striated sphincter: 
1. Striated musculature that is a part of the outer 
wall of the proximal urethra in both male and 
f...
ANATOMY OF BLADDER & ITS OUTLET
 Bladder storage & emptying requires continual 
coordination of detrusor & external urinary 
sphincter (EUS), mediated by...
DEFINITION 
Dyssynergia: 
 Kinesiologic disassociation of two groups of muscles that 
generally work in harmony. 
Sphinct...
Detrusor sphincter dyssynergia (DSD): 
defined by the ICS as 
 Impaired coordination between detrusor and 
sphincter duri...
 Smooth sphincter dyssynergia or Proximal 
sphincter dyssynergia occurs in an individual with 
autonomic hyperreflexia/dy...
ETIOLOGY 
 Common causes: 
traumatic SCI, 
 multiple sclerosis, 
 Spinal dysraphism, and 
 various forms of transvers...
PATHOPHYSIOLOGY 
 During normal filling, pelvic nerve afferents are 
modulated by sympathetic output to cause relaxation ...
 During voluntary micturition, inhibitory 
signals from frontal cortex to PMC are removed 
thus allowing activation of mi...
 DSD occurs in the setting of neurological 
abnormalities b/w PMC and sacral spinal cord. 
 This interruption of the spi...
CLASSIFICATION 
BLAIVAS CLASSIFICATION: 
 Type 1: 
concomitant increase in both detrusor pressure & 
EMG activity; 
at ...
 Type 3: 
 Crescendo-decrescendo pattern of sphincter 
contraction that results in outlet obstruction 
throughout entire...
TYPE 1 DESD
TYPE 2 DESD
TYPE 3 DESD
CORRELATION b/w DSD type & degree of 
SCI lesions: 
 Incomplete sensory and motor lesion → type 1 
DESD. 
 Complete sens...
PSEUDO DYSSYNERGIA: 
 Pseudodyssynergia is the presence of EUS 
contraction occurring during micturition that may 
be mis...
Common causes of pseudodyssynergia include 
(1) abdominal straining to either initiate or augment a 
bladder contraction o...
 Pseudodyssynergia can reliably be differentiated 
from true DESD urodynamically by analyzing the 
patterns of detrusor a...
EPIDEMIOLOGY 
 The precise incidence of DSD is unknown given the 
variability in neurological disease. 
 SCI contributes...
CLINICAL PRESENTATION 
 Mixed storage and voiding symptoms, 
 Urinary incontinence or 
 Complications of DSD, i.e. UTIs...
DIAGNOSTIC EVALUATION 
HISTORY AND PHYSICAL EXAMINATION: 
 Aim to diagnose the cause & nature of bladder 
dysfunction, & ...
 Screening for occult neurological disease: inquiry 
regarding visual changes, back or neck pain, 
weakness, paraesthesia...
 DRE is necessary to assess anal sphincter tone at 
rest and during voluntary contraction. 
 Testing perineal sensation,...
BASIC INVESTIGATIONS: 
 Urine culture and sensitivity, if there is a suspicion 
of UTI. 
 Serum electrolytes, urea & cre...
URODYNAMICS 
 Urodynamics: critical role in detection of DSD and 
monitoring for associated complications. 
 DSD can be ...
 Diagnosis of DSD by EMG requires elevated ‘EMG 
activity during detrusor contraction, in the absence 
of Valsalva and Cr...
Paediatric patient with SCI with DSD showing dilated posterior urethra 
& 
bladder neck during bladder contraction on VCUG...
EMG Vs VCUG 
 Diagnostic discrepancy between EMG & VCUG 
ranges from 40% to 46%. 
 Males more often diagnosed with EMG w...
 Role of urethral pressure profilometry in diagnosis 
of DSD is controversial. 
 Unfortunately, a perfect test for DSD d...
COMPLICATIONS 
 DESD results in a high bladder pressure with 
subsequent back pressure effects. 
 The rate of urological...
 If left untreated, DESD can result in: 
• UTI/Urosepsis 
• VUR 
• Hydronephrosis 
• Upper tract deterioration 
• Renal i...
TREATMENT 
Goals of treatment: 
 Adequate storage at low intravesical pressure. 
 Adequate emptying at low intravesical ...
 Type 1 DESD: observation alone unless there is 
persistent reflux, hydronephrosis, or autonomic 
hyperreflexia. 
 Types...
Current approaches: 
1-Chronic indwelling catheterization. 
2-Intermittent self catheterization. 
3-Pharmacological therap...
C.I.S.C. 
 Intermittent catheterisation combined with 
anticholinergics to reduce detrusor pressures is the 
most common ...
Surgical Sphincterotomy 
 Therapeutic destruction of the external urethral 
sphincter. 
 A surgical incision into the sp...
 The 12-o’clock sphincterotomy (Madersbacher and 
Scott), remains the procedure of choice for a number 
of reasons: 
 Ma...
Early failure due to 
 an inadequate surgical procedure (either not deep 
enough or not extensive enough), 
 inadequate ...
Failure defined as 
1. presence of large PVRU associated with UTI 
2. autonomic hyperreflexia symptomatology 
associated w...
 Lower urinary tract complications may occur: 
 Recurrent infection, calculi, urethral diverticula, 
stricture, bladder ...
Urethral Stenting 
 Use of a urethral stent to bypass the striated 
sphincter. 
 A significant decrease in 
1. detrusor ...
UroLume Urethral Stent
The Urolume (cont.)
Complications include 
 obstruction by urothelial ingrowth, 
 stent encrustation, 
 stricture, 
 stent migration,& 
 ...
Pharmacologic Sphincterotomy 
 Periurethral injections of botulinum A toxin. 
 Acts by inhibiting acetylcholine release ...
Urethral Overdilatation 
 Urethral overdilatation through the use of urethral 
sounds or balloon procedures may improve 
...
Neuromodulation 
 Pudendal nerve interruption is seldom performed 
today due to potential complications, including 
impot...
THANK YOU !!!
D.s.d.
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D.s.d.

  1. 1. DETRUSOR SPHINCTER GAURAV NAHAR DNB UROLOGY(STD. ) MMHRC DYSSYNERGIA
  2. 2. INTRODUCTION MICTURITION CYCLE:  Micturition cycle involves two relatively discrete processes: 1. bladder filling and urine storage and 2. bladder emptying or voiding
  3. 3. Bladder filling and urine storage :  Accommodation of increasing volumes of urine at a low intravesical pressure (normal compliance) and with appropriate sensation.  A bladder outlet that is closed at rest and remains so during increases in intra-abdominal pressure.  Absence of involuntary bladder contractions (detrusor overactivity).
  4. 4. Bladder emptying/voiding :  A coordinated contraction of bladder smooth musculature of adequate magnitude and duration.  A concomitant lowering of resistance at the level of the smooth and striated sphincter (no functional obstruction).  Absence of anatomic (as opposed to functional) obstruction.
  5. 5. NEURAL CONTROL OF THE LOWER URINARY TRACT  Peripheral Nervous System: The lower urinary tract is innervated by 3 sets of peripheral nerves involving parasympathetic, sympathetic, & somatic nervous systems. 1. Pelvic parasympathetic nerves arise at the sacral level of the spinal cord, excite the bladder, and relax the urethra. 2. Lumbar sympathetic nerves inhibit the bladder body and excite the bladder base and urethra. 3. Pudendal nerves excite the external urethral sphincter.
  6. 6. Mechanism of storage and voiding reflexes A) Storage reflexes.  During urine storage, distention of bladder produces low-level bladder afferent firing.  This stimulates (a)sympathetic outflow to the bladder outlet (base and urethra), and (b)pudendal outflow to the external urethral sphincter.  These responses occur by spinal reflex pathways & represent “guarding reflexes,” which promote continence.  Sympathetic firing also inhibits detrusor muscle and transmission in bladder ganglia.
  7. 7. B) Voiding reflexes.  At the initiation of micturition, intense vesical afferent activity activates brainstem micturition center(PMC), which inhibits spinal guarding reflexes (sympathetic and pudendal outflow to the urethra).  PMC also stimulates parasympathetic outflow to bladder & internal sphincter smooth muscle.
  8. 8. Smooth sphincter :  Smooth musculature of the bladder neck and proximal urethra.  A physiologic (but not anatomic )sphincter.  Not under voluntary control.
  9. 9. Striated sphincter: 1. Striated musculature that is a part of the outer wall of the proximal urethra in both male and female. a/k/s intrinsic or intramural striated sphincter or rhabdosphincter, & 2. bulky skeletal muscle group that closely surrounds the urethra at the level of the membranous portion in the male and primarily the middle segment in the female a/k/s extrinsic or extramural striated sphincter.  The extramural portion is the classically described external urethral sphincter and is under voluntary control.
  10. 10. ANATOMY OF BLADDER & ITS OUTLET
  11. 11.  Bladder storage & emptying requires continual coordination of detrusor & external urinary sphincter (EUS), mediated by central & peripheral nervous systems.  Neurological conditions, lesions or trauma can cause disturbances in urinary storage and voiding, resulting in bladder dysfunction.
  12. 12. DEFINITION Dyssynergia:  Kinesiologic disassociation of two groups of muscles that generally work in harmony. Sphincter dyssynergia:  An involuntary contraction or lack of relaxation of either the striated sphincter (the striated muscle surrounding the proximal urethra and the striated muscle that forms a part of the urethra for a variable distance from the “urogenital diaphragm” to the bladder neck) or the smooth sphincter (the smooth muscle of the bladder neck and proximal urethra).
  13. 13. Detrusor sphincter dyssynergia (DSD): defined by the ICS as  Impaired coordination between detrusor and sphincter during voiding due to a neurologic abnormality (i.e. detrusor contraction synchronous with contraction of the urethral and/or periurethral striated muscles).  unless specified otherwise, refers to dyssynergia of the striated sphincter.  detrusor striated-sphincter dyssynergia and detrusor external-sphincter dyssynergia.
  14. 14.  Smooth sphincter dyssynergia or Proximal sphincter dyssynergia occurs in an individual with autonomic hyperreflexia/dysreflexia (Spinal cord injury above T6 level).  True DESD: only in patients who have an abnormality in pathways between sacral spinal cord & brainstem PMC.  Detrusor sphincter dyssynergia (DSD) is the most common cause of neurogenic sphincteric obstruction.
  15. 15. ETIOLOGY  Common causes: traumatic SCI,  multiple sclerosis,  Spinal dysraphism, and  various forms of transverse myelitis.
  16. 16. PATHOPHYSIOLOGY  During normal filling, pelvic nerve afferents are modulated by sympathetic output to cause relaxation of the detrusor while maintaining the tone of the bladder neck sphincter.  There is tonic activity of EUS facilitated by input from PMC.
  17. 17.  During voluntary micturition, inhibitory signals from frontal cortex to PMC are removed thus allowing activation of micturition reflex.  The PMC inhibits spinal guarding reflexes and transmits excitatory signals to bladder.  The EUS relaxes with synergistic contraction of the detrusor for a coordinated decrease in urethral pressure and rise in detrusor pressure to allow the outflow of urine.
  18. 18.  DSD occurs in the setting of neurological abnormalities b/w PMC and sacral spinal cord.  This interruption of the spinobulbospinal pathways → failed inhibition of spinal guarding reflexes + erroneous excitation of Onuf’s nucleus causing EUS contraction to occur during detrusor contraction, generating elevated detrusor pressures.
  19. 19. CLASSIFICATION BLAIVAS CLASSIFICATION:  Type 1: concomitant increase in both detrusor pressure & EMG activity; at the peak of detrusor contraction, sphincter suddenly relaxes & unobstructed voiding occurs.  Type 2: Sporadic/clonic contractions of striated sphincter intermittently during detrusor contraction. Intermittent urinary stream.
  20. 20.  Type 3:  Crescendo-decrescendo pattern of sphincter contraction that results in outlet obstruction throughout entire detrusor contraction.  Urinary obstruction & Inability to urinate.
  21. 21. TYPE 1 DESD
  22. 22. TYPE 2 DESD
  23. 23. TYPE 3 DESD
  24. 24. CORRELATION b/w DSD type & degree of SCI lesions:  Incomplete sensory and motor lesion → type 1 DESD.  Complete sensory and motor lesions → type 2 and type 3. WELD CLASSIFICATION:  Continuous DESD.  Intermittent DESD.
  25. 25. PSEUDO DYSSYNERGIA:  Pseudodyssynergia is the presence of EUS contraction occurring during micturition that may be misinterpreted for DSD.  Sphincter EMG activity increases simultaneously with intravesical or detrusor pressure.
  26. 26. Common causes of pseudodyssynergia include (1) abdominal straining to either initiate or augment a bladder contraction or in response to discomfort and (2) attempted inhibition of a bladder contraction either because of its involuntary nature or because of discomfort.
  27. 27.  Pseudodyssynergia can reliably be differentiated from true DESD urodynamically by analyzing the patterns of detrusor and EMG activity.
  28. 28. EPIDEMIOLOGY  The precise incidence of DSD is unknown given the variability in neurological disease.  SCI contributes to a significant portion of cases of DSD.  ≈ 75% of patients with suprasacral SCI have DSD.  Incidence of DSD in MS and spinal dysraphism is estimated at 25 – 50%.
  29. 29. CLINICAL PRESENTATION  Mixed storage and voiding symptoms,  Urinary incontinence or  Complications of DSD, i.e. UTIs and bladder calculi.  Neurological symptoms may predominate and trigger initial neurourological investigation.
  30. 30. DIAGNOSTIC EVALUATION HISTORY AND PHYSICAL EXAMINATION:  Aim to diagnose the cause & nature of bladder dysfunction, &  To identify associated complications.  assess for changes in urinary, bowel and neurological symptoms,  Disease duration, severity, prior investigations and treatments.
  31. 31.  Screening for occult neurological disease: inquiry regarding visual changes, back or neck pain, weakness, paraesthesia, urinary or bowel symptoms.  Abdominal examination: assess for palpable bladder, constipation, tenderness and previous incisions.  Genitalia: inspected for abnormality and skin irritation
  32. 32.  DRE is necessary to assess anal sphincter tone at rest and during voluntary contraction.  Testing perineal sensation, bulbocavernosus reflex and cremasteric reflexes.
  33. 33. BASIC INVESTIGATIONS:  Urine culture and sensitivity, if there is a suspicion of UTI.  Serum electrolytes, urea & creatinine.  Voiding diaries helpful in characterising voiding dysfunction.  Ultrasonography helpful for assessment of hydronephrosis, urinary calculi & post-void residual urine volumes.
  34. 34. URODYNAMICS  Urodynamics: critical role in detection of DSD and monitoring for associated complications.  DSD can be diagnosed using electromyography (EMG), voiding cystourethrogram (VCUG) and/or urethral pressure profilometry.
  35. 35.  Diagnosis of DSD by EMG requires elevated ‘EMG activity during detrusor contraction, in the absence of Valsalva and Crede manoeuvres .’  Typical VCUG findings: a closed bladder neck during filling and subsequent dilation of bladder neck & proximal urethra to the level of EUS during micturition.
  36. 36. Paediatric patient with SCI with DSD showing dilated posterior urethra & bladder neck during bladder contraction on VCUG.
  37. 37. EMG Vs VCUG  Diagnostic discrepancy between EMG & VCUG ranges from 40% to 46%.  Males more often diagnosed with EMG whereas females more often diagnosed by VCUG.  Diagnosis of DSD in males by VCUG may be impaired due to anatomical BOO by prostate and that in the female diagnosis by EMG may be impaired due to increased electrode artefact.
  38. 38.  Role of urethral pressure profilometry in diagnosis of DSD is controversial.  Unfortunately, a perfect test for DSD does not exist.  Detection of DSD can be improved by using both EMG and VCUG.  Pathology such as BOO, Parkinson’s disease and dysfunctional voiding should be considered before diagnosis, as they may have similar symptomatology.
  39. 39. COMPLICATIONS  DESD results in a high bladder pressure with subsequent back pressure effects.  The rate of urological complications from DESD with no intervention is 50%.  Complications are much less common in females because of decreased detrusor pressures generated.
  40. 40.  If left untreated, DESD can result in: • UTI/Urosepsis • VUR • Hydronephrosis • Upper tract deterioration • Renal insufficiency • Urolithiasis
  41. 41. TREATMENT Goals of treatment:  Adequate storage at low intravesical pressure.  Adequate emptying at low intravesical pressure.  Absence or control of infection.  Upper urinary tract preservation or improvement.  Social acceptability and adaptability.
  42. 42.  Type 1 DESD: observation alone unless there is persistent reflux, hydronephrosis, or autonomic hyperreflexia.  Types 2 and 3: treated.  DLPP>40 cm water- significantly higher incidence of upper tract damage and persistent DESD, hence warrants treatment.
  43. 43. Current approaches: 1-Chronic indwelling catheterization. 2-Intermittent self catheterization. 3-Pharmacological therapy. 4-Bladder reconstruction and urinary diversion. 5-External sphincterotomy. 6- Stent placement(Urolume)across the sphincter. 7-Sphincter ablation with Botulinum toxin inj. 8-Intrathecal continuous baclofen infusion. 9-Balloon dilatation. 10-Laser sphincter ablation
  44. 44. C.I.S.C.  Intermittent catheterisation combined with anticholinergics to reduce detrusor pressures is the most common treatment for DSD.  Pharmacotherapy has a limited role in the management of DSD.
  45. 45. Surgical Sphincterotomy  Therapeutic destruction of the external urethral sphincter.  A surgical incision into the sphincter muscle to open it, then urine drains out and collected by condom drainage.  Female anatomy does not allow for condom drainage as an alternative.
  46. 46.  The 12-o’clock sphincterotomy (Madersbacher and Scott), remains the procedure of choice for a number of reasons:  Main bulk of the sphincter is anteromedial. With the blood supply primarily lateral, a 12-o’clock incision is least likely to cause hemorrhage.  The rate of postoperative erectile dysfunction with this incision is approximately 5%.
  47. 47. Early failure due to  an inadequate surgical procedure (either not deep enough or not extensive enough),  inadequate detrusor function, and  bladder neck or prostatic obstruction. Late failure may occur because of  fibrosis somewhere along the extent of the sphincterotomy,  a change in detrusor function,  development of prostatic obstruction, or  a change in neurologic status such that smooth sphincter dyssynergia develops.
  48. 48. Failure defined as 1. presence of large PVRU associated with UTI 2. autonomic hyperreflexia symptomatology associated with bladder overdistention or high voiding pressures, and/or 3. progressive upper tract deterioration from persistent reflux or poor bladder emptying.
  49. 49.  Lower urinary tract complications may occur:  Recurrent infection, calculi, urethral diverticula, stricture, bladder neck stenosis, and recurrent epididymitis.
  50. 50. Urethral Stenting  Use of a urethral stent to bypass the striated sphincter.  A significant decrease in 1. detrusor leak point pressure 2. residual urine volume 3. Mean voiding pressure 4. symptoms of autonomic dysreflexia.  One obvious advantage: sphincteric stent is potentially reversible.
  51. 51. UroLume Urethral Stent
  52. 52. The Urolume (cont.)
  53. 53. Complications include  obstruction by urothelial ingrowth,  stent encrustation,  stricture,  stent migration,&  UTI.
  54. 54. Pharmacologic Sphincterotomy  Periurethral injections of botulinum A toxin.  Acts by inhibiting acetylcholine release from presynantic cholinergic nerve terminals, thereby inhibiting striated & smooth muscle contractions.  Use remains uncommon & unclear.
  55. 55. Urethral Overdilatation  Urethral overdilatation through the use of urethral sounds or balloon procedures may improve compliance and decrease outlet resistance.  Urethral overdilatation to 40 to 50 Fr in females & 22 to 28 Fr in 11 myelodysplastic children with high intravesical pressures refractory to traditional forms of treatment.  An ineffective long-term treatment for striated sphincter dyssynergia.
  56. 56. Neuromodulation  Pudendal nerve interruption is seldom performed today due to potential complications, including impotence and significant fecal and stress urinary incontinence.  Dorsal root rhizotomy with sacral anterior nerve root stimulation.
  57. 57. THANK YOU !!!

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