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DNB UROLOGY(STD. )
Micturition cycle involves two relatively discrete
1. bladder filling and urine storage and
2. bladder emptying or voiding
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
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
Absence of anatomic (as opposed to functional)
NEURAL CONTROL OF THE LOWER URINARY
Peripheral Nervous System: The lower urinary tract is
innervated by 3 sets of peripheral nerves involving
parasympathetic, sympathetic, & somatic nervous
1. Pelvic parasympathetic nerves arise at the sacral level
of the spinal cord, excite the bladder, and relax the
2. Lumbar sympathetic nerves inhibit the bladder body
and excite the bladder base and urethra.
3. Pudendal nerves excite the external urethral
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
Sympathetic firing also inhibits detrusor muscle
and transmission in bladder ganglia.
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
PMC also stimulates parasympathetic outflow to
bladder & internal sphincter smooth muscle.
Smooth sphincter :
Smooth musculature of the bladder neck and
A physiologic (but not anatomic )sphincter.
Not under voluntary control.
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
Bladder storage & emptying requires continual
coordination of detrusor & external urinary
sphincter (EUS), mediated by central & peripheral
Neurological conditions, lesions or trauma can cause
disturbances in urinary storage and voiding,
resulting in bladder dysfunction.
Kinesiologic disassociation of two groups of muscles that
generally work in harmony.
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).
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.
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
Spinal dysraphism, and
various forms of transverse myelitis.
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
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.
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
concomitant increase in both detrusor pressure &
at the peak of detrusor contraction, sphincter
suddenly relaxes & unobstructed voiding occurs.
Sporadic/clonic contractions of striated
sphincter intermittently during detrusor
Intermittent urinary stream.
Crescendo-decrescendo pattern of sphincter
contraction that results in outlet obstruction
throughout entire detrusor contraction.
Urinary obstruction & Inability to urinate.
CORRELATION b/w DSD type & degree of
Incomplete sensory and motor lesion → type 1
Complete sensory and motor lesions → type 2 and
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.
Common causes of pseudodyssynergia include
(1) abdominal straining to either initiate or augment a
bladder contraction or in response to discomfort
(2) attempted inhibition of a bladder contraction
either because of its involuntary nature or because
Pseudodyssynergia can reliably be differentiated
from true DESD urodynamically by analyzing the
patterns of detrusor and EMG activity.
The precise incidence of DSD is unknown given the
variability in neurological disease.
SCI contributes to a significant portion of cases of
≈ 75% of patients with suprasacral SCI have DSD.
Incidence of DSD in MS and spinal dysraphism is
estimated at 25 – 50%.
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.
HISTORY AND PHYSICAL EXAMINATION:
Aim to diagnose the cause & nature of bladder
To identify associated complications.
assess for changes in urinary, bowel and neurological
Disease duration, severity, prior investigations and
Screening for occult neurological disease: inquiry
regarding visual changes, back or neck pain,
weakness, paraesthesia, urinary or bowel
Abdominal examination: assess for palpable
bladder, constipation, tenderness and previous
Genitalia: inspected for abnormality and skin
DRE is necessary to assess anal sphincter tone at
rest and during voluntary contraction.
Testing perineal sensation, bulbocavernosus reflex
and cremasteric reflexes.
Urine culture and sensitivity, if there is a suspicion
Serum electrolytes, urea & creatinine.
Voiding diaries helpful in characterising voiding
Ultrasonography helpful for assessment of
hydronephrosis, urinary calculi & post-void
residual urine volumes.
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.
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
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 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.
Role of urethral pressure profilometry in diagnosis
of DSD is controversial.
Unfortunately, a perfect test for DSD does not
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
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.
If left untreated, DESD can result in:
• Upper tract deterioration
• Renal insufficiency
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.
Type 1 DESD: observation alone unless there is
persistent reflux, hydronephrosis, or autonomic
Types 2 and 3: treated.
DLPP>40 cm water- significantly higher incidence
of upper tract damage and persistent DESD, hence
1-Chronic indwelling catheterization.
2-Intermittent self catheterization.
4-Bladder reconstruction and urinary diversion.
6- Stent placement(Urolume)across the sphincter.
7-Sphincter ablation with Botulinum toxin inj.
8-Intrathecal continuous baclofen infusion.
10-Laser sphincter ablation
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.
Therapeutic destruction of the external urethral
A surgical incision into the sphincter muscle to open
it, then urine drains out and collected by condom
Female anatomy does not allow for condom drainage
as an alternative.
The 12-o’clock sphincterotomy (Madersbacher and
Scott), remains the procedure of choice for a number
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%.
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
a change in detrusor function,
development of prostatic obstruction, or
a change in neurologic status such that smooth sphincter
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.
Use of a urethral stent to bypass the striated
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
obstruction by urothelial ingrowth,
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.
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
An ineffective long-term treatment for striated
Pudendal nerve interruption is seldom performed
today due to potential complications, including
impotence and significant fecal and stress urinary
Dorsal root rhizotomy with sacral anterior nerve root