To compare the urodynamic study variables at the onset of vesicoureteral reflux (VUR) between the overactive and underactive bladders in patients with spinal cord injury who presented with VUR.
A total of 28 (13 cases of detrusor overactivity and 15 detrusor underactivity) men were enrolled. We compared the urodynamic variables between the two groups; detrusor pressure and bladder compliance, the infused volume at the onset of VUR measured on a voiding cystourethrography and cystometric capacity, maximum detrusor pressure, and bladder compliance during filling cystometry were recorded.
At the onset of VUR, the bladder volume and compliance, except for the detrusor pressure, showed a significant difference between the two groups. The detrusor pressure, bladder volume, and bladder compliance relative to the cystometric capacity showed a significant difference between the two groups. The detrusor pressure, bladder volume, and bladder compliance at the onset of VUR relative to the cystometric bladder capacity did not show any significant difference between the two groups.
There were differences in some variables at the onset of VUR depending on the type of neurogenic bladder. The VUR occurred at a lower capacity in neurogenic bladder with detrusor overactivity than in neurogenic bladder with detrusor underactivity at the same pressure. VUR occurred at a lower intravesical pressure compared to that known as the critical detrusor pressure (≥40 cm H2O) required for the development of VUR. The results of our study demonstrate that the detrusor pressure should be maintained lower than the well known effective critical detrusor pressure for the prevention and treatment of VUR.
Citations
Objective: To evaluate the effectiveness of conservative treatment for the vesicoureteral reflux (VUR) in spinal cord injured patients.
Method: Twelve spinal cord injured patients were diagnosed as VUR which was graded as the International Classification System by voiding cystourethrography (VCUG). They received conservative treatment including clean intermittent catheterization, administration of anticholinergics and intravesical oxybutynin instillation therapy. Pre-treatment urodynamic studies and VCUG were compared with follow-up studies after conservative treatment. The results of follow-up VCUG were graded as controlled or remained group.
Results: After conservative treatment, VUR was controlled in 8 patients (67.0%) and remained in 4 patients (33.0%). On urodynamic studies after conservative treatment, mean maximal bladder capacity increased from 225.0 to 370.6 ml (p＜0.05), mean bladder compliance increased from 12.1 to 31.5 ml/cmH2O (p＜0.05), mean maximal detrusor pressure decreased from 63.8 to 21.8 cmH2O (p＜0.05) in controlled group. But in remained group, there was no significant difference between pre & post-treatment. There was singnificant difference in change ratio of maximal detrusor pressure between two groups (p＜0.05).
Conclusion: This study showed 67.0% controlled rate of VUR by VCUG with improved urodynamic parameters after conservative treatment. We conclude that VUR can be effectively managed by the conservative method in spinal cord injured patients. (J Korean Acad Rehab Med 2002; 26: 299-305)
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.
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.
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