Citations
To investigate the effect of radiofrequency (RF) sacral rhizotomy of the intolerable neurogenic bladder in spinal cord injured patients.
Percutaneous RF sacral rhizotomy was performed on 12 spinal cord injured patients who had neurogenic bladder manifested with urinary incontinence resisted to an oral and intravesical anticholinergic instillation treatment. Various combinations of S2, S3, and S4 RF rhizotomies were performed. The urodynamic study (UDS) was performed 1 week before RF rhizotomy. The voiding cystourethrogram (VCUG) and voiding diaries were compared 1 week before and 4 weeks after therapy. Total volume of daily urinary incontinence (ml/day) and clean intermittent catheterization (ml/time) volume of each time were also monitored.
After RF sacral rhizotomy, bladder capacity increased in 9 patients and the amount of daily urinary incontinence decreased in 11 patients. The mean maximal bladder capacity increased from 292.5 to 383.3 ml (p<0.05) and mean daily incontinent volume decreased from 255 to 65 ml (p<0.05). Bladder trabeculation and vesicoureteral reflux findings did not change 4 weeks after therapy.
This study revealed that RF sacral rhizotomy was an effective method for neurogenic bladder with uncontrolled incontinence using conventional therapy among spinal cord injured patients.
Citations
Method: 34 spinal cord injured male patients were participated in this study. We measured the maximal detrusor pressure, compliance of detrusor, involuntary detrusor reflex and urethral pressure by urodynamic study. And we induced ejaculatory stimulation by vibratory (FerticareⰒ) and electrical stimulation (SeagerⰒ) and analyzed the sperm volume, the concentration, the total sperm count, the motile sperm count and motility. Analysis of variance (ANOVA) and paired t-test were used to compare sperm quality among groups of urodynamic parameters.
Results: Semen quality such as sperm concentration, sperm volume, motile sperm count was significantly (p＜0.05) better in patients with low maximal detrusor pressure, high detrusor compliance, normtonic urethral pressure than with high maximal detrusor pressure, low detrusor compliance, hypertonic urethral pressure, regardless of involuntary detrusor reflex.
Conclusion: The proper management of neurogenic bladder for improving semen quality in spinal cord injured male patients may be needed for better pregnant outcomes. (J Korean Acad Rehab Med 2003; 27: 875-879)
Method: Thirty-five female Lewis rats were used in the study. Thirteen rats used as normal cystometrogram controls. Twenty-two rats induced EAE were divided into two groups: ten rats as control and twelve rats as dexamethasone injection group. Bladder dysfunction by cystometrogram, severity of weakness, and duration of paralysis were evaluated every other day after the onset of paralysis.
Results: Dexamethasone injection group compared to control group presented short duration of bladder dysfunction (2.5 vs. 4.2 day, p＜0.05) and paralysis (4.5 vs. 7.3 day, p＜0.05). There was a trend for lesser paralysis in the dexamethasone injection group, than control group (weakness scores were 2.4 vs. 3.6, p＞0.05), but it was not statistically significant.
Conclusion: Dexamethasone ameliorates the course of paralysis and bladder dysfunction in EAE. We suggest that dexamethasone treatment is an effective method in treating neurogenic bladder and paralysis in multiple sclerosis.
Method: Thirteen adults with CP were participated in this study. Nine of these thirteen subjects had urological symptoms. The urological history taking, urine analysis, urine culture, voiding cystourethrography (VCUG) and urodynamic study were done.
Results: The urinary incontinence was the most common presenting symptom. All subjects without urological symptoms showed normal urodynamic findings. Eight of the subjects who had urological symptoms had abnormal findings on urodynamic study. All subjects showed normal findings on voiding cystourethrography. Based on urodynamic findings, six subjects were treated with anticholinergic drug and five (83.3%) of these subjects showed improvement of their urological symptoms.
Conclusion: Many adults with CP might have the problems in urination. Our study showed that many symptomatic subjects had abnormal urodynamic findings and much of these urological symptoms was improved with proper treatment. These adults with CP would, therefore, benefit from proper assessment and treatment, expecially in the subjects who have urological symptoms. (J Korean Acad Rehab Med 2003; 27: 198-203)
Method: The subjects were 65 patients with neurogenic bladder. The causes of neurogenic bladder were consist of seven brain lesions; 39 spinal cord injuries; 15 cauda equina syndromes; and four peripheral polyneuropathies. PSEP and EBCR were done.
Results: Of the patients with hyperreflexic bladder (43.1%), PSEP latency was normal in 21.4%, delayed in 21.4%, and not obtainable in 57.2%. Of the patients with areflexic bladder (56.9%), PSEP latency was normal in 24.3%, delayed in 21.6%, and not obtainable in 54.1%. Of the patients with hyperreflexic bladder, EBCR latency was normal in 82.1%, delayed in 14.3%, and not obtainable in 3.6%. Of the patients with areflexic bladder, EBCR latency was normal in 16.2%, delayed in 37.8%, and not obtainable in 46.0% (p＜0.01).
Conclusion: There was significant correlation between EBCR and type of neurogenic bladder, but not with PSEP. These results seem to be reflected from the neuro-anatomical lesion of the neurogenic bladder. (J Korean Acad Rehab Med 2003; 27: 70-74)
Objective: To investigate the immediate effect of dorsal penile nerve (DPN) stimulation on detrusor pressure (Pdet) and blood pressure (BP) during hyper-reflexic contractions of the bladder in patients with cervical spinal cord injury (SCI).
Method: The subjects were eight male patients with cervical SCI who had symptoms of autonomic dysreflexia. During water-cystometry, BP was monitored using an intra-arterial catheter into the radial artery, and was recorded simultaneously with the Pdet. Electrical stimulation was applied to the DPN, using surface electrodes each time a bladder contraction was detected. Baseline BP and BP at the first and the last hyper-reflexic contractions of bladder were measured with Pdet, respectively.
Results: As Pdet increased, the BP increased in all cases. The reflex contractions of the bladder were effectively suppressed by DPN stimulation, and as the Pdet decreased during stimulation, radial arterial pressure also decreased immediately and significantly.
Conclusion: DPN stimulation can lower both Pdet and the elevated BP. (J Korean Acad Rehab Med 2002; 26: 409- 413)
Objective: The aims of this study is to determine the influence of the imbalance between sympathetic and parasympathetic nervous input to colon transit control in spinal cord injured patients and the effect of the anticholinergic medication for neurogenic bladder on colon transit time.
Method: Eighty-six patients with cervical and thoracic cord injury were enrolled. The colon transit time (CTT) according to the severity and lesion of injury and also the administration routes of oxybutynin were compared by independent t-test.
Results: Total CTT was 56.7 hours, with right CTT 16.9 hours, left CTT 21.3 hours and rectosigmoid CTT 18.5 hours. The rectosigmoid CTT of the patients with the lesion at T6 or below were prolonged than that of the patients with the lesion above T6 (p＜0.05). According to administration route of oxybutynin, instillation group showed more shortened rectosigmoid CTT than oral route group (p＜0.05).
Conclusion: The imbalance between parasympathetic and sympathetic outflow from the spinal cord has play an important role in colon transit control of spinal cord injured patients. The management of neurogenic bowel and bladder considering colon transit time is needed for the effective management of spinal cord injured patients. (J Korean Acad Rehab Med 2002; 26: 292-298)
Objective: To evaluate the inhibition effects of hyper-reflexic detrusor activity by sacral afferent nerve stimulation in spinal cord injury (SCI) patients.
Method: The subjects were thirteen patients with SCI who had symptoms of urinary incontinence, because of hyper-reflexic bladder contractions. According to the level and severity of injury, the patients were divided into groups of tetraplegia/paraplegia and complete/incomplete. We applied dorsal penile nerve (DPN) stimulation using portable stimulator during the continuous bladder filling. Stimulation parameters were biphasic rectangular pulses of 25 Hz frequency, 250 microseconds pulse width. Stimulation intensity was twice the threshold of pudendo-anal reflex. The one minute stimulation was repeated to every reflex contraction during the cystometry. Immediate suppressive effect of DPN was analyzed.
Results: Of 13 patients who had a reflex bladder, hyper-reflexic detrusor contractions were suppressed effectively in 12 by DPN stimulation. The suppressive effect in groups of level and severity was not statistically significant.
Conclusion: DPN stimulation for inhibition of hyper-reflexic bladder contraction is an adjunctive method of incontinence management in SCI patients of different level and severity.
Objective: The aim of this study was to investigate the efficacy of capsaicin, a neurotoxin for C-fiber afferents, applied intravesically in the treatment of neurogenic bladder with detrusor hyperreflexia (DH).
Method: Six subjects, three women and three men with traumatic spinal cord injury who had neurogenic bladder manifested with DH and urinary incontinence resistant to oral and intravesical anticholinergic instillation treatment were tried with intravesical administration of capsaicin (1 mmol/l 100 ml) for 30 minutes. Single instillation was given in five subjects and two instillations in one. Maximal detrusor pressure and maximal bladder volume were monitored by the portable cystometer. Follow-up monitor of pressure and volume was recorded after 1 week and every 3 weeks afterwards for 21 weeks, with one exception (31 weeks).
Results: Average maximal detrusor pressure decreased by 50.8% and average bladder capacity at maximal detrusor pressure increased by 68% in five subjects after single instillation of capsaicin. Clinical benefit from single instillation lasted over 21 weeks and same as the subject with two instillations. Maximal effect on detrusor pressure appears during 6∼9 weeks period and bladder capacity during 9∼15 weeks period. Although autonomic dysreflexia in 5 of 6 subjects during instillation and macroscopic hematuria in 2 subjects during the 1st two days were noted, they were resolved spontaneously.
Conclusion: Single and repeated intravesical instillation of capsaicin were safe and effective in the management of neurogenic bladder with DH in traumatic spinal cord injured patients.
Significant technical advance during the past decade have influenced the manner in which electrical stimulation may be administered to assist the functional recovery of paralyzed organ. Functional electrical stimulation (FES) is defined as the use of electrical stimulation to activate paralyzed or paretic muscles in precise sequence and intensity to assist in the performance of activities of daily living. An FES system generally consists of a control unit, stimulator unit, and electrode. The control unit determines the intensity of electrical stimulus applied to the patient through the electrodes. The stimulator unit generates the electrical stimulus. Depending on the application, FES components may be worn externally or surgically implanted. Hand neuroprosthesis system can enhance significantly the upper extremity functions of quadriplegics. Several lower extremity systems with and without bracing are being investigated for the purpose of ambulation, transfer, and standing for persons with paraplegia. Diaphragmatic pacing can be used as more physiologic artificial ventilator for high quadriplegic patient with respiratory failure. System for bladder contraction can provide catheter-free micturition for persons with supra-sacral cord injury. While there appears to be great potential for its use in a number of medical conditions, further research and clinical study is needed to truly demonstrate its clinical benefit before it gains more widespread acceptance and use.
Conclusion:
Objective: The purpose of this study was to determine the clinical usefulness of KCl provocative urodynamic study in spinal cord injured patients with neurogenic bladder.
Method: Urodynamic studies using normal saline and 0.2 M KCl solution were performed on 46 spinal cord injured patients. The reflex volume was measured on urodynamic study using normal saline and 0.2 M KCl solution. If the reflex volume using KCl solution was smaller than 85% of reflex volume using normal saline, it was considered as positive response. Urine culture and urinalysis were also performed before urodynamic study.
Results: KCl provocative tests showed positive response in patients showing current infection on urine culture and urinalysis (p＜0.05). Comparing with the positive response group and negative response group, mean maximal bladder capacity was smaller and mean bladder compliance was lower in the positive response group (p＜0.05). No significant differences were found between positive and negative response groups according to age, duration since injury, completeness of injury, voiding methods, and anticholinergic medication. The mean reflex volume provoked by KCl solution was smaller and mean bladder compliance provoked by KCl solution was lower than those provoked by normal saline in the positive response group (p＜0.01).
Conclusion: The response of KCl provocative test suggested increased bladder-blood-urine barrier permeability by current urinary tract infection. We conclude that the KCl provocative urodynamic study is a useful method for detection of impaired bladder-blood-urine barrier in spinal cord injuries with neurogenic bladder.
Objective: The purposes of our study were to determine the effect of serial radioisotope renography on the diagnostic evaluation and therapeutic intervention of spinal cord injured patients and to determine the characteristics of renographic findings in spinal cord injured patients.
Method: Three hundred and two spinal cord injured patients were examined with radioisotope renography using Technetium-99m mercaptoacetyltriglycine. Forty-two of 302 patients were examined in serial studies. Intravenous pyelogram, urodynamic study, 24-hour creatinine clearance, and voiding cystourethrogram were also performed. Radioisotope renography was correlated with diagnostic procedures and therapeutic interventions. Therapeutic interventions included changes in medication and bladder management.
Results: The renal functions in the left kidney were better than the functions in the right kidney after spinal cord injury (p＜0.01). If neurogenic bladders were managed properly, renal functions improved after the shock stage of injury (p＜0.05). Patients with significant improvement in their renal function underwent changes in proper medication and methods of bladder management (p＜0.05). Renal function changes were correlated with the type of neurogenic bladder and maximal detrusor pressure (p＜0.05). No significant renal function changes were found between the groups according to the completeness of injury and gender.
Conclusion: Radioisotope renography is a good initial indicator to show problems that required management changes. Serial radioisotope renographic findings give valuable informations about the urinary tract in spinal cord injured patients.
Objective: To determine the clinical utility of ice water test for the urodynamic study in neurogenic bladder of spinal cord injured patients.
Method: Warm water (20∼30oC) urodynamic studies were performed on 66 spinal cord injured patients. Subsequently, ice water (4∼8oC) urodynamic studies were performed. We determined the ice water test to be positive if the reflex volume of ice water urodynamic study is lower than the volume of the warm water urodynamic study.
Results: Ice water test was positive in 24 (55.8%) and negative in 19 (44.2%) of the 43 patients showing hyperreflexic detrusor activity in warm water urodynamic study. Ice water test was negative in all 23 cases showing areflexic detrusor activity. No significant difference was found between positive and negative ice water test groups for the level of injury, sex, age, extent of injury and duration since injury. If water was cool enough, positivity of ice water test was not affected by infusion rate. There was no difference between the two urodynamic studies of maximal bladder pressure and compliance.
Conclusion: This study suggests that ice water urodynamic study is a useful method for the evaluation of hyperreflexic neurogenic bladder activated by cold specific receptors via C afferent fibers in spinal cord injured patients.
In spinal cord injury, various options exist for the management of the neurogenic bladder. For the management of neurogenic bladder, urethral stent was placed under a cystoscopic guidance as one day procedure. Urethral stents were inserted in a T12 spinal cord injured patient who had recurrent urinary tract infections and a vesicoureteral reflux (VUR) and a T3 spinal cord injured patient who had a detrusor-sphincter dyssynergia. In the first case, recurrent urinary tract infection and VUR were resolved after the stenting. In the second case, urethral stent was removed because of the failure of continuous drainage. Because of its easily reversible nature, the urethral stent can be adopted for use in pateints as an option of neurogenic bladder management.
Objective: The purpose of this study was to evaluate the clinical effectiveness of intravesical oxybutynin chloride instillation in the management of neurogenic bladder dysfunction in spinal cord injured patients.
Method: Fifty-two spinal cord injured patients with hyperreflexic or hypertonic neurogenic bladder were treated with intravesical oxybutynin instillation therapy. The purified oxybutynin chloride was dissolved in sterile water and mixed with normal saline. This oxybutynin solution was instilled twice a day for 7 days. The urodynamic studies were compared before and after the instillation. Total volume of daily incontinence was also monitored.
Results: After the intravesical oxybutynin instillations, mean maximal bladder capacity increased from 212.13 to 323.81 ml (p＜0.01), mean bladder compliance increased from 11.73 to 18.56 ml/cmH2O (p＜0.01), mean maximal detrusor pressure decreased from 67.19 to 50.90 cmH2O (p＜0.01) and mean daily amount of incontinence decreased from 735.58 to 201.73 ml (p＜0.01). No significant differences were found between the groups according to the level of injury, completeness of injury, duration since onset of injury and the presence of asymptomatic bacteriuria.
Conclusion: This study proved that intravesical instillation of oxybutynin solution is an effective method in spinal cord injured patients with hyperreflexic or hypertonic neurogenic bladder dysfunction regardless the level and completeness of injury, as well as duration since the onset of injury or the presence of asymptomatic bacteriuria.
Objective: The purposes of this study were 1) to evaluate the effectiveness of follow-up urologic evaluation of neurogenic bladder in patients with spinal cord injury, 2) to define risk factors causing upper urinary tract complications, and 3) to evaluate changes of the vesicoureteral reflux grade on follow-up study.
Method: Urodynamic studys, ultrasonographys, and voiding cystourethrographys of 90 patients with spinal cord injury who admitted to the bladder clinic of National Rehabilitation Hostpital were evaluated. Of the 90 patients, twenty four patients (27%) had upper urinary tract complication (vesicoureteral reflux or hydronephrosis). The risk factors of upper urinary tract complication were compared. The patients who had vesicoureteral reflux were devided into two main groups: conservative medical treatment group (oxybutynin, atropine intravesical instillation and intermittent catheterization) and primary surgical treatment group, and then the changes of the vesicoureteral reflux grade on follow-up study were evlauated.
Results: 1) The incidence of upper urinary tract complication was 27% for all patients. After bladder clinic evaluation, the patients who were recommended the change of the voiding mothods were 24%, and 58% of the patients were need management to decrease maximal detrusor pressure.
2) Maximal bladder capacity by clinical voiding chart recording (≤250 ml), bladder wall deformity (≥trabeculation grade 2), leak point pressure (≥40 cmH20), and maximal detrusor pressure (≥90 cmH2O) were significantly different between patients with upper urinary tract complication and patients without that. 3) In the eight vesicoureteral reflux patients, five of six patients were cured or improved with conservative treatment and two patients were cured with surgical treatment.
Conclusion: The periodic follow-up evaluation of neurogenic bladder of spinal cord injured patients was important to prevent upper urinary tract deterioration. The factors related upper urinary tract complication were clinical bladder capacity, leak point pressure, bladder wall deformity (trabeculation) and maximal detrusor pressure.
Objective: The purpose of this study is to evaluate the effects of regular sports activity on psychosocial adaptation, natural killer cell activity (NKCA) as an immunologic measure and HDL-cholesterol level as an indirect index of heart disease in chronic spinal cord injured persons.
Method: We compared two groups. One is sports group (n=13) who has been doing regular sports activity more than three hours a week for at least one year. Another group who leads sedentary life matched age and body mass index served as a control group (n=13). For the evaluation of psychosocial adaptation, we assessed Rosenberg Self Esteem Scale as subjective measure, Craig Handicap Assessment and Reporting Technique (CHART) as objective measure and Symptom Checklist 90 Revision (SCL-90-R) as a psychologic evaluation. NKCA and serum HDL-cholesterol level were assessed.
Results: There was no significant difference in subjective measure and psychologic evaluation between two groups. CHART score and NKCA are significantly higher in the sports group than in the control group (p＜0.05). HDL cholesterol level was increased in the sports group compared with the control group.
Conclusion: Participating in regular sports activity improved the psychosocial adaptation and immune system in chronic spinal cord injured persons.
Neurogenic bladder in patients with spinal cord injury can lead to a rapid deterioration of renal function by compromise of the upper urinary tracts. Algorithm of neurogenic bladder management in spinal cord injury has been discussed according to the types of neurogenic bladder and the hand function of patients. Although intermittent catheterization with a low intravesical pressure has been generally known as the best method of neurogenic bladder management in the patients with spinal cord injury, the most popular method of neurogenic bladder management for the patients with spinal cord injury in Korea has been reported as reflex voiding up to the present. It is necessary to identify the reasons for patients not to continue intermittent catheterization after discharge from inpatient rehabilitation care.
Objective: To evaluate the changes of bladder management methods after the discharge from hospital, and to identify the problems associated with their method changes of bladder management after the discharge.
Method: The subjects of this study were 128 spinal cord injury patients with a neurogenic bladder dysfunction who were admitted to the hospital and received the neurogenic bladder management and training. We reviewed the medical records of these patients for the management methods of neurogenic bladder and interviewed the patients whether they are still using the same methods after the discharge.
Results: The number of patients who were doing the intermittent catheterization at the time of discharge from hospital was markedly reduced after the discharge and most of the patients in this group have switched to the external collecting device method, using Cred, Valsalva or tapping method. The reasons of this change were that the intermittent catheterization method was not only difficulty and complicated but also restricted their social activities.
Conclusion: We concluded that a long term close follow up and continuous encouragement are very important in the management of neurogenic bladder patients who are discharged with the intermittent catheterization method.
Objective: To investigate the correlations of neurological level, BCR and urodynamic study (UDS) in the spinal cord injury(SCI) patients, we analyzed the results of BCR and UDS fundings.
Method: The sujects were twenty-four patients with SCI who were beyond 3 months following the SCI. According to the level of injury, the patients were divided into 3 groups: above T10 level, 7; T10 to L2 level, 8; below L2 level, 9. Electrophysiological BCR test and UDS were performed in all patients.
Results: The results showed a significant correlation between the BCR test and level of injury, however there was no correlation between the UDS and level of injury, nor between the detrusor function and BCR test. The results might be from a differential recovery of the somatic and autonomic nervous system.
Conclusion: As a part of comprehensive evaluation for the bladder function in the SCI patients, we recommend both the bulbocavernosus reflex test and urodynamic study. Further neurophysiological research would be needed to understand the urodynamic findings which did not correlate with the level of SCI.
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