TRACT DYSFUNCTION

TRACT DYSFUNCTION

NLUTD refers to bladder and/or urethral sphincteric disorders that result from neurological lesions. Discrete neurological lesions will a ff ect LUT storage and voiding in a consistent manner depending on the site of the lesion, the nature of the lesion (destructive, inflammatory , irritative) and the extent of the lesion (complete or incomplete). Neurological lesions can be classified based on location as suprapontine, spinal (infrapontine–suprasacral) and sacral/infrasacral. Each has characteristic clinical and urodynamic features ( Figure 83.22 ). Suprapontine lesions (e.g. cerebrovascular accident, Parkinson’s disease, brain injury) lead to storage LUTS owing to loss of inhibition from higher brain centres. This results in neurogenic detrusor overactivity , but since local sacral micturition refluxes are preserved the voiding phase is intact. Spinal lesions (e.g. spinal cord injury [SCI], myelitis, disc herniation) can have the most serious impact as they can lead to both detrusor overactivity and sphincteric overactivity (DSD), resulting in high-pressure voiding, which risks deterioration in renal function. Furthermore, patients with spinal lesions above the T6 spinal cord level are at risk of developing autonomic dysreflexia (see Autonomic dysrefl exia ). Sacral and infrasacral lesions are relatively safe as they result in low-pressure underactive bladder and/or sphincter function. Patients predominantly

Over

active : insignificant PVR urine volume : detrusor overactivity Normoactive Over

active : PVR urine volume usually raised : detrusor overactivity, detrusor–sphincter Overactive : PVR urine volume raised Under

Under- : hypocontractile or active active Normoactive Underactive from Panicker JN, Lancet Neurol 2015;

bladder emptying) and SUI. The aims of treatment in NLUTD are to: 1 preserve renal function by ensuring low-pressure storage and voiding; 2 achieve continence; 3 prevent UTI. Treatment of detrusor overactivity and poor compliance in order to attain low-pressure storage is achieved through the conservative, medical and sur gical treatment pathways outlined above for the treatment of UUI. Treatment of sphincteric overactivity or DSD to attain low-pressure voiding is typically achieved by CISC, although sphincteric overactivity can be treated with intrasphincteric BTX-A, sacral neuromodulation, SNS or direct sphincterotomy . If these methods are ine ff ective or unsuitable for the patient, continent diversion (appendico vesicostomy) can be performed to prevent high-pressure voiding. Detrusor underactivity is managed with CISC and sphincteric underactivity is treated as described above for SUI. Several factors should be considered when managing patients with NLUTD . These relate to patient factors (body habitus, hand function, motivation and level of compliance, mental status, values and preferences, support network) and neurological disease factors (prognosis).