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Iatrogenic Dilatation of the Upper Urinary Tract During Radiographic Evaluation of Patients with Spinal Cord Injury
0022-534 7/86/1351-0078$02.00/00 Vol. 135, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1986 by The Williams & Wilkins Co.
IATROGENIC DILATATION OF THE UPPER URINARY TRACT DURING RADIOGRAPHIC EVALUATION OF PATIENTS WITH SPINAL CORD INJURY S. L. STOVER, D. M. WITTEN, K. V. KUHLEMEIER, L. KEITH LLOYD
AND
P.R. FINE
From the Department of Rehabilitation Medicine, and Urological Rehabilitation and Research Center, University of Alabama in Birmingham, Birmingham, Alabama
ABSTRACT
Patients with upper and lower motor neuron spinal cord mJuries were observed to determine whether cystography immediately before excretory urography induced iatrogenic dilatation of the upper urinary tract that was indistinguishable from true pathological dilatation. Evidence is given that such dilatation occurs. This iatrogenic dilatation is not seen in patients with normally innervated urinary tracts and appears to be caused by exaggerated bladder reflexes in patients with upper motor neuron lesions. Bladder spasms precipitated by cystographic contrast material also may create vesicoureteral obstruction and lead to dilatation of the upper urinary tract. Consequently, it is suggested that cystography should not immediately precede excretory urography. When such a sequence is necessary, room or body temperature contrast medium should be used for the cystogram, the bladder should be emptied before the excretory urogram is started and a 1-hour interval should be allowed between the 2 procedures. The findings also suggest that any factors that induce repeated or continuing bladder spasms may contribute to progressive dilatation of the upper urinary tract. Currently accepted criteria for normal radiographic parameters are based on data acquired from persons with normally innervated urinary tracts. However, clinical studies have shown that neurogenic bladders and normally innervated bladders react differently to the same stimuli, 1 • 2 complicating the evaluation of neurogenic bladders. Moreover, there are 2 distinctly different types of neurogenic bladders, each having its own unique characteristics. 3 An upper motor neuron bladder is hyperreflexic owing to loss of inhibition and control of the sacral spinal cord reflexes. A lower motor neuron bladder is characterized by an interruption of its reflex arc and a consequent decrease or loss in reflex capacity. Certain clinical observations have raised concern about the relationship between the dynamics of hyperactive bladder reflexes and the function of the upper urinary tract. For example, 3 patients in this center with neurologically complete upper m9tor neuron spinal cord injuries, who were free of a catheter and on external condom drainage, were evaluated with a diagnostic cystogram and excretory urogram (IVP) during a regularly scheduled annual examination. Each patient had ureterectasis and pyelocaliectasis, although none had vesicoureteral reflux. Surgical intervention was considered necessary to prevent further deterioration. For various reasons the IVP was repeated in each patient before an external sphincterotomy was performed. In each case the upper urinary tracts then were considered normal. The sole common characteristic in all 3 patients was the fact that a cystogram was performed immediately before the IVP in the initial evaluation, whereas in the subsequent preoperative re-evaluations only IVPs were performed. It was hypothesized that the hyperreflexic upper motor neuron bladder, when stimulated by cystography per se or the contrast medium used in the procedure, might be responsible for those upper urinary tract changes detected during the diagnostic process. Subsequently, a series of studies was implemented to examine the possibility that upper urinary tract changes may be induced by the particular sequence of diagnostic procedures, rather than being truly reflective of upper tract pathological conditions.
MATERIAL AND METHODS
A study population consisting of 16 spinal cord injury patients at least 1 year post-injury with neurologically complete upper or lower motor neuron lesions was divided into 3 groups. Some patients were tested more than once (table 1). All but patient 9 were men. An IVP was performed on all patients via the following technique. A scout film was obtained, after which 100 cc con-
TABLE
1. Summary of project studies by patient, bladder type and
subgroup Pt.
Bladder Type
1 Upper motor
Group 2-Room Group 1-Iced Group 3-Catheter C t t M d. Temperature Contrast Traction on ras e mm Medium Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Done
Done
Not done
Done
Not done
Not done
Done
Done
Not done
Done
Not done
Not done
Done
Not done
Done
Done
Done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
neuron
2 Upper motor neuron 3 Upper motor neuron 4 Upper motor neuron 5 Upper motor neuron 6 Lower motor neuron 7 Upper motor neuron 8 Upper motor neuron 9 Upper motor neuron 10 Upper motor neuron 11 Upper motor neuron 12 Upper motor neuron 13 Lower motor neuron 14 Lower motor neuron 15 Upper motor neuron 16 Upper motor neuron
Accepted for publication September 23, 1985. Supported by Grants 13-P-59349/4-03 and G008300053 from the National Institute for Handicapped Research.
78
IATROGENIC RADIOG~RAPHIC URil~ARY ·TH,ACT AB:NOHTvii\LIT1ES AIF'TE:It
trast material were injected ,n 10 ~~m n A sequence of 14 17 -inch radio graphs of the kidneys, ureters and bladder was taken 3 to 8 minutes after injection of the contrast material, accompanied by videomonitoring, videotaping and appropriate spot x-ray films to document all observations. No attempts were made to record pressures. Attempts to determine the rate and rhythm of ureteral peristalsis during videomonitoring were considered unreliable. Specific anatomical parameters (table 2) were graded 6 to 8 minutes after injection of the contrast material. Eight minutes after injection of the contrast material a 16F indwelling catheter was inserted into the bladder and the retention balloon was filled with 5 cc water. The upper and lower urinary tracts were observed for 1 minute after catheter insertion for changes in the bladder, ureters and kidneys but none was seen in any patient tested. From this point, the study differed for the 3 groups as follows. Group 1 (11 patients). After the residual urographic contrast material was drained from the bladder, cystographic contrast material (iothalamate meglumine 17.2 per cent), thoroughly cooled in an ice bath, was introduced into the bladder through the catheter at a rate determined by gravity flow, up to a pressure of 30 to 35 cm. water. The kidneys, ureters and bladder were observed as the contrast material entered the bladder. For the next 5 minutes the kidneys, ureters and bladder were visualized by videomonitoring, and changes were documented with appropriate videotaping and spot x-ray films. Group 2 (4 patients). The same procedure was used as in group 1, except that room temperature cystographic contrast material was introduced into the bladdeL Group 3 (6 patients). Manual traction was applied ~o the catheter for at least 1 minute. During traction and for 5 mmutes thereafter, the kidneys, ureters and bladder were visualized again by videomonitoring, and changes were documented with appropriate videotaping and spot x-ray films. The radiographs, spot films and videotapes were reviewed and graded by at least 2 clinicians following the procedure. Caliceal blunting and ureterectasis were graded as 0-none, 1-minimal, 2-moderate and 3-severe.
RESULTS
0
TABLE 2.
The '"'""'°"'n,·,c from 1 of the initial 3 who served this (patient 5) are shown in figure l. as a stimulus Fieure 2 includes IVPs cystograms fron1 patient 7, who had a dramatic change in the upper and lower tracts after int:wduction of iced contrast material. In group 1 the introduction of iced cystc;grapn1c contrast material produced increased bladder indicative of exaggerated bladder reflexes and vesical spasm in all 9 patients with upper motor neuron lesions and in 1 of 2 with lower motor neuron lesions Of the 9 patients with upper motor neuron lesions 7 showed some degree of ureterectasis but no evidence of ureterectasis was detected in both patients with lower motor neuron lesions. Pyelocaliectasis was detected in 5 of 9 patients with upper motor neuron lesions and in neither with a lower motor neuron lesion. The artifactual ureterectasis and pyelocaliectasis did not appear to occur more frequently on the right or left side. When room temperature cystographic contrast medium was used (group 2), the only changes detected occurred in 1 patient with a lower motor neuron lesion who had mild bladder trabeculation and in another with an upper motor neuron lesion who had minimal ureterectasis. While catheter traction in group 3 caused minimal bladder changes, ureterectasis was detected in only 1 of these 6 patients (table 2). This patient had an upper motor neuron lesion. There were no changes resembling pyelocaliectasis in the group tested with catheter traction. DISCUSSION
This suggests that and technical factors must be considered carefully when cystograms and IVPs are evaluated from patients with neurogenic bladders, especially those with upper motor neuron lesions. Bladder hyperreflexia may be elicited by a variety of stimuli. Exaggerated reflexes may lead to changes that are not seen routinely in persons with normal innervation of the urinary tract. Moderate catheter traction often elicited increased bladder
Summary of studies
Bladder Trabeculation Pt. No.
COH.D
Ureterectasis (rt.flt.)
Bladder Type Before
After
Pyelocaliectasis (rt./ It.)
Before
After
Before
After
0/0 1/1 1/0 0/2 1/1 0/0 0/0 0/0 0/0 0/1 0/0
1/1 1/1 1/1 2/3 1/1 0/0 1/1 1/1 1/1 l+/1+ 0/0
0/1 1/0 0/0 0/2 1/1 0/0 1/0 0/0 0/0 1/0 0/0
0/1 1/0 0/0 1/3 2/1 0/0 2/2 0/0 1/1 l+/0 0/0
1/1 0/0 0/0 1/1
1/1 0/0 1/1 1/1
1/1 0/0 0/0 0/0
1/1 0/0 0/0 0/0
0/0 0/0 2/2 0/1 0/0 1/1
0/0 1/1 2/2 0/1 0/0 1/1
0/0 0/0 1/1 1/0 1/0 1/1
0/0 0/0 1/1 1/0 1/0 1/1
Group I -iced contra..st medium 1 2 3 4
5 6
7 8 9 11
14
Upper Upper Upper Upper Upper Lower Upper Upper Upper Upper Lower
motor motor motor motor motor motor motor motor motor motor motor
neuron neuron neuron neuron neuron neuron neuron neuron neuron neuron neuron
0 0 0 1
1 2
0
3
0 0 0 0
1 2 3
Not available 1
2 2 1
Group 2-room temperature contrast medium 13 14 15 16
Lower Lower Upper Upper
motor motor motor motor
neuron neuron neuron neuron
2 1 0 0
1 1 0 0
Group 3-catheter traction 8 9
10 11
12 13
Upper Upper Upper Upper Upper Lower
motor motor motor motor motor motor
neuron neuron neuron neuron neuron neuron
0 0 0 Not available Not available 1
Not available 1 0
2 2
2
Grading of trabeculation. ureterectasis and pyelocaliectasis: 0-absent, 1-minimal, 2-moderate and 3-severe.
80
STOVER AND ASSOCIATES
FIG. 1. Studies of 17-year-old man with C5 quadriplegia. Radiographs A to C were done on same day with cystogram preceding IVP. A, cystogram before IVP shows contracted, trabeculated bladder. B, 5-minute film of IVP following cystogram shows dilatation of ureters. C, 10minute film following cystogram shows bilateral grade 2 pyelocaliectasis. D, subsequent normal IVP 7 weeks later without intervening therapy.
contraction but rarely was severe enough to cause ureterectasis; pyelocaliectasis was not observed. We acknowledge that iced contrast material is not used routinely for cystography. However, it was used in this study to induce exaggerated reflex changes that would allow the effects of bladder hyperreflexia on the upper and lower urinary tract to be studied. The use of iced contrast material elicited lower and upper tract changes, sometimes marked, in many patients. Of 11 patients who had no evidence of ureterectasis before bladder filling with iced contrast material 7 exhibited ureterectasis subsequent to instillation of iced contrast material during cystography. Five of 11 patients suffered from an increase in pyelocaliectasis during the procedure. Most but not all of the patients with iatrogenic ureterectasis also had iatrogenic pyelocaliectasis. Patients 5 and 8, with marked bladder changes after instillation of iced contrast material, had only minimal changes in the upper tracts. Likewise, patients 4 and
7, who exhibited moderate upper tract changes subsequent to bladder filling with iced contrast material, had modest concurrent bladder changes. Thus, it appears that these artificial bladder and upper tract changes are related. Our findings of bladder changes induced by use of cold contrast material corroborate previous reports from other researchers. 4 •5 The lower urinary tract also may be influenced by technical factors, such as the type of contrast medium used. 2• 6 However, only minimal bladder or upper tract changes were seen in our patients during catheter traction. Since bladder and ureteral dynamics are associated closely in persons with normal innervation of the urinary tract, it is not surprising that the upper urinary tracts of these patients exhibited changes resulting from changes occurring in over-all bladder dynamics. This is especially true when bladder dynamics are exaggerated by increased reflex activity, such as that typically associated with upper motor neuron lesions.
IATROGENIC RADIOGRAPHIC URINARY TRACT ABNORJMALITIES AFTER SPINAL CORD INJUR':'
81
FIG. 2. Studies of 19-year-old man with C4 quadriplegia. A, baseline IVP. B, introduction of iced contrast medium into bladder shows contraction and trabeculation of bladder with apparent obstruction at vesicoureteral junction. C, dilatation of ureter and calices after iced contrast medium.
Many independent investigators have presented data to support this hypothesis. Davis and associates studied a series of patients with vesicoureteral reflux and demonstrated that resting ureteral pressure and contractility were affected by changes in bladder pressure and volume. 7 Subsequent studies also demonstrated this relationship in patients without reflux. 8 Voluntary retention of urine in normal children occasionally produces ureteral dilatation and in some cases simulates hydronephrosis. 9· 10 Indeed, this technique has been used to enhance delineation of the pelviocaliceal system and ureters in children11 and adults. 12 Consistent bladder volumes in excess of 375 cc may increase the dimensions and filling of the upper urinary tract to the point of being considered pathological dilatation. 13 Bladder distension may cause a decrease in the renal excretory clearance of urea and, to a lesser extent, the clearance of creatinine.13 The degree of filling of the upper tract also is influenced by the status of hydration, diuresis, and the extent of pathological obstruction. 14- 16 Bladder distension also may alter ureteral peristalsis as well as ureteral dimension. We observed that bladder spasms constrict the flow of urine from the distal ureter into the bladder at the intramural ureter, causing ureterectasis and pyelocaliectasis. Trigonal stretching during bladder filling may attenuate and narrow the intramural ureter, resulting in a physiological ureteral obstruction. 17 Studies in dogs have shown an increase in the amplitude and frequency of ureteral peristalsis with a full bladder. 18• 19 However, this compensating increase inureteral peristalsis eventually is overcome and the ureters eventually distend with a higher resting pressure. 17 Recognizing the fact that multiple factors may be responsible for the phenomenon observed in our study, we hypothesize that the bladder spasms, from whatever cause, seen in spinal cord injury patients with upper motor neuron lesions may lead to vesicoureteral obstruction. This lack of urine transport through the ureters gives the appearance of ureteral and caliceal distension during an IVP. Our findings also suggest that patients with upper motor neuron lesions who experience severe bladder spasms may suffer intermittent obstruction similar to those precipitated by radiographic procedures. It is possible that a patient with increased external sphincter tone and detrusor-sphincter dyssynergia may have an intermittent or chronic increase in the intravesical pressure and coexistent bladder spasms, both of which may impede ureterovesical flow and lead to hydronephrosis. Resistance to ureteral emptying may have implications related to chronic urinary tract infection, impaired renal function and/or urolithiasis.
We believe that our findings dictate caution in the interpretation of contemporaneous IVPs and cystograms, and observe the following guidelines in our clinic. 1) A cystogram should not be performed immediately before an IVP in patients with neurogenic bladders. However, if this sequence cannot be avoided because of the need to evaluate for possible vesicoureteral reflux, an adequate recovery period of at least 1 hour should be allowed between the 2 procedures. 2) The bladder should be emptied completely before an IVP is performed. 3) Cystogram contrast material should be at room or body temperature to avoid inducing artificial changes in bladder configuration. Additional studies are needed to determine whether bladder spasms are capable of creating vesicoureteral obstructions of sufficient magnitude and severity to impair ureteral emptying to a clinically significant degree. REFERENCES
1. Govan, D. E. and Engelsgjerd, G. L.: A method of cystometry to
2. 3. 4. 5,
6. 7. 8. 9. 10.
record bladder activity in neurogenic dysfunction. Arch. Phys. Med., 49: 21, 1968. Scher, A. T.: An evaluation of discrepancy in capacity and contour of the neurogenic bladder as shown on cystography and pyelography. Paraplegia, 17: 358, 1979. Krane, R. J. and Siroky, M. B.: Classification of neuro-urologic disorders. In: Clinical Neuro-Urology. Boston: Little, Brown & Co., chapt. 9, 143, 1979. Rhodes, D. W., M. R and Morrow, J, VV.: Use of the iced cystogram to differentiate bladder neck and external sphincter obstruction. J. UI"OI., 119: 639, 1978. Pearman, J. W., Low, A. L and Fisher, A. A,: The "iced cystogram" -a new technique for distinguishing obstruction at the level of the external sphincter from obstruction at the bladder neck. Paraplegia, 12: 153, 1974. McAlister, W. H., Shackelford, G. D. and Kissane, J.: The histologic effects of 30 percent Cystokon, Hypaque 25 percent and Renografin-30 in the bladder. Radiology, 104: 563, 1972. Davis, D. M., Zimskind, P. D. and Paquet, J.-P.: Studies on urodynamics: new light on ureteral function. J. Urol., 90: 150, 1963. Zimskind, P. D.: The influence of bladder dynamics on ureteral dynamics. In: Urodynamics. Edited by W. Lutzeyer and H. Melchior. New York: Springer-Verlag, p. 154, 1973. Nogrady, M. B., Dunbar, J. S. and MacEwan, D. W.: The effect of (voluntary) bladder distention on the intravenous pyelogram: an experimental study. Amer. J. Roentgen., 90: 37, 1963. Berdon, W. E. and Baker, D. H.: The significance of a distended bladder in the interpretation of intravenous pyelograms obtained on patients with "hydronephrosis". Amer. J. Roentgen., 120: 402, 1974.
82
STOVER AND ASSOCIATES
11. Pajewski, M. and Manor, A.: Enhanced intravenous urography in infants and children produced by distension of the urinary bladder. Clin. Rad., 24: 376, 1973. 12. Pajewski, M., Manor, A. and Gil, I.: Diagnostic value of distended urinary bladder pyelography in adults. Isr. J. Med. Sci., 18: 854, 1982. 13. Gill, W. B. and Curtis, G. A.: The influence of bladder fullness on upper urinary tract dimensions and renal excretory function. J. Urol., 11 7: 573, 1977. 14. Boyarsky, S.: Urodynamic studies. In: Diagnostic Urology. Edited by J. Glenn. New York: Harper & Row Publishers, Inc., chapt. 6, p. 126, 1964. 15. Emmett, J. L.: Clinical Urography, 2nd ed. Philadelphia: W. B. Saunders Co., 1964.
16. Friedenberg, R. M.: Radiographic examination of the ureter. In: The Ureter. Edited by H. Bergman. New York: Harper & Row Publishers, Inc., chapt. 9, p. 188, 1967. 17. Tanagho, E. A., Hutch, J. A., Meyers, F. H. and Rambo, 0. N., Jr.: Primary vesicoureteral reflux: experimental studies of its etiology. J. Urol., 93: 165, 1965. 18. Anderson, G. F., Pierce, J. M., Jr. and Fredericks, C. M.: The ureteral response to bladder filling. In: Urodynamics: Hydrodynamics of the Ureter and Renal Pelvis. Edited by S. Boyarsky, C. W. Gottshalk, E. A. Tanagho and P. D. Zimskind. New York: Academic Press, Inc., chapt. 21, p. 283, 1971. 19. Rosen, D. I., Constantinou, C. E., Sands, J.P. and Govan, D. E.: Dynamics of the upper urinary tract: effects of changes in bladder pressure on ureteral peristalsis. J. Urol., 106: 209, 1971.
THE JOURNAL OF UROLOGY
Copyright© 1986 by The Williams & Wilkins Co.
IATROGENIC DILATATION OF THE UPPER URINARY TRACT DURING RADIOGRAPHIC EVALUATION OF PATIENTS WITH SPINAL CORD INJURY S. L. STOVER, D. M. WITTEN, K. V. KUHLEMEIER, L. KEITH LLOYD
AND
P.R. FINE
From the Department of Rehabilitation Medicine, and Urological Rehabilitation and Research Center, University of Alabama in Birmingham, Birmingham, Alabama
ABSTRACT
Patients with upper and lower motor neuron spinal cord mJuries were observed to determine whether cystography immediately before excretory urography induced iatrogenic dilatation of the upper urinary tract that was indistinguishable from true pathological dilatation. Evidence is given that such dilatation occurs. This iatrogenic dilatation is not seen in patients with normally innervated urinary tracts and appears to be caused by exaggerated bladder reflexes in patients with upper motor neuron lesions. Bladder spasms precipitated by cystographic contrast material also may create vesicoureteral obstruction and lead to dilatation of the upper urinary tract. Consequently, it is suggested that cystography should not immediately precede excretory urography. When such a sequence is necessary, room or body temperature contrast medium should be used for the cystogram, the bladder should be emptied before the excretory urogram is started and a 1-hour interval should be allowed between the 2 procedures. The findings also suggest that any factors that induce repeated or continuing bladder spasms may contribute to progressive dilatation of the upper urinary tract. Currently accepted criteria for normal radiographic parameters are based on data acquired from persons with normally innervated urinary tracts. However, clinical studies have shown that neurogenic bladders and normally innervated bladders react differently to the same stimuli, 1 • 2 complicating the evaluation of neurogenic bladders. Moreover, there are 2 distinctly different types of neurogenic bladders, each having its own unique characteristics. 3 An upper motor neuron bladder is hyperreflexic owing to loss of inhibition and control of the sacral spinal cord reflexes. A lower motor neuron bladder is characterized by an interruption of its reflex arc and a consequent decrease or loss in reflex capacity. Certain clinical observations have raised concern about the relationship between the dynamics of hyperactive bladder reflexes and the function of the upper urinary tract. For example, 3 patients in this center with neurologically complete upper m9tor neuron spinal cord injuries, who were free of a catheter and on external condom drainage, were evaluated with a diagnostic cystogram and excretory urogram (IVP) during a regularly scheduled annual examination. Each patient had ureterectasis and pyelocaliectasis, although none had vesicoureteral reflux. Surgical intervention was considered necessary to prevent further deterioration. For various reasons the IVP was repeated in each patient before an external sphincterotomy was performed. In each case the upper urinary tracts then were considered normal. The sole common characteristic in all 3 patients was the fact that a cystogram was performed immediately before the IVP in the initial evaluation, whereas in the subsequent preoperative re-evaluations only IVPs were performed. It was hypothesized that the hyperreflexic upper motor neuron bladder, when stimulated by cystography per se or the contrast medium used in the procedure, might be responsible for those upper urinary tract changes detected during the diagnostic process. Subsequently, a series of studies was implemented to examine the possibility that upper urinary tract changes may be induced by the particular sequence of diagnostic procedures, rather than being truly reflective of upper tract pathological conditions.
MATERIAL AND METHODS
A study population consisting of 16 spinal cord injury patients at least 1 year post-injury with neurologically complete upper or lower motor neuron lesions was divided into 3 groups. Some patients were tested more than once (table 1). All but patient 9 were men. An IVP was performed on all patients via the following technique. A scout film was obtained, after which 100 cc con-
TABLE
1. Summary of project studies by patient, bladder type and
subgroup Pt.
Bladder Type
1 Upper motor
Group 2-Room Group 1-Iced Group 3-Catheter C t t M d. Temperature Contrast Traction on ras e mm Medium Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
Done
Done
Not done
Done
Not done
Not done
Done
Done
Not done
Done
Not done
Not done
Done
Not done
Done
Done
Done
Done
Not done
Not done
Done
Not done
Not done
Done
Not done
neuron
2 Upper motor neuron 3 Upper motor neuron 4 Upper motor neuron 5 Upper motor neuron 6 Lower motor neuron 7 Upper motor neuron 8 Upper motor neuron 9 Upper motor neuron 10 Upper motor neuron 11 Upper motor neuron 12 Upper motor neuron 13 Lower motor neuron 14 Lower motor neuron 15 Upper motor neuron 16 Upper motor neuron
Accepted for publication September 23, 1985. Supported by Grants 13-P-59349/4-03 and G008300053 from the National Institute for Handicapped Research.
78
IATROGENIC RADIOG~RAPHIC URil~ARY ·TH,ACT AB:NOHTvii\LIT1ES AIF'TE:It
trast material were injected ,n 10 ~~m n A sequence of 14 17 -inch radio graphs of the kidneys, ureters and bladder was taken 3 to 8 minutes after injection of the contrast material, accompanied by videomonitoring, videotaping and appropriate spot x-ray films to document all observations. No attempts were made to record pressures. Attempts to determine the rate and rhythm of ureteral peristalsis during videomonitoring were considered unreliable. Specific anatomical parameters (table 2) were graded 6 to 8 minutes after injection of the contrast material. Eight minutes after injection of the contrast material a 16F indwelling catheter was inserted into the bladder and the retention balloon was filled with 5 cc water. The upper and lower urinary tracts were observed for 1 minute after catheter insertion for changes in the bladder, ureters and kidneys but none was seen in any patient tested. From this point, the study differed for the 3 groups as follows. Group 1 (11 patients). After the residual urographic contrast material was drained from the bladder, cystographic contrast material (iothalamate meglumine 17.2 per cent), thoroughly cooled in an ice bath, was introduced into the bladder through the catheter at a rate determined by gravity flow, up to a pressure of 30 to 35 cm. water. The kidneys, ureters and bladder were observed as the contrast material entered the bladder. For the next 5 minutes the kidneys, ureters and bladder were visualized by videomonitoring, and changes were documented with appropriate videotaping and spot x-ray films. Group 2 (4 patients). The same procedure was used as in group 1, except that room temperature cystographic contrast material was introduced into the bladdeL Group 3 (6 patients). Manual traction was applied ~o the catheter for at least 1 minute. During traction and for 5 mmutes thereafter, the kidneys, ureters and bladder were visualized again by videomonitoring, and changes were documented with appropriate videotaping and spot x-ray films. The radiographs, spot films and videotapes were reviewed and graded by at least 2 clinicians following the procedure. Caliceal blunting and ureterectasis were graded as 0-none, 1-minimal, 2-moderate and 3-severe.
RESULTS
0
TABLE 2.
The '"'""'°"'n,·,c from 1 of the initial 3 who served this (patient 5) are shown in figure l. as a stimulus Fieure 2 includes IVPs cystograms fron1 patient 7, who had a dramatic change in the upper and lower tracts after int:wduction of iced contrast material. In group 1 the introduction of iced cystc;grapn1c contrast material produced increased bladder indicative of exaggerated bladder reflexes and vesical spasm in all 9 patients with upper motor neuron lesions and in 1 of 2 with lower motor neuron lesions Of the 9 patients with upper motor neuron lesions 7 showed some degree of ureterectasis but no evidence of ureterectasis was detected in both patients with lower motor neuron lesions. Pyelocaliectasis was detected in 5 of 9 patients with upper motor neuron lesions and in neither with a lower motor neuron lesion. The artifactual ureterectasis and pyelocaliectasis did not appear to occur more frequently on the right or left side. When room temperature cystographic contrast medium was used (group 2), the only changes detected occurred in 1 patient with a lower motor neuron lesion who had mild bladder trabeculation and in another with an upper motor neuron lesion who had minimal ureterectasis. While catheter traction in group 3 caused minimal bladder changes, ureterectasis was detected in only 1 of these 6 patients (table 2). This patient had an upper motor neuron lesion. There were no changes resembling pyelocaliectasis in the group tested with catheter traction. DISCUSSION
This suggests that and technical factors must be considered carefully when cystograms and IVPs are evaluated from patients with neurogenic bladders, especially those with upper motor neuron lesions. Bladder hyperreflexia may be elicited by a variety of stimuli. Exaggerated reflexes may lead to changes that are not seen routinely in persons with normal innervation of the urinary tract. Moderate catheter traction often elicited increased bladder
Summary of studies
Bladder Trabeculation Pt. No.
COH.D
Ureterectasis (rt.flt.)
Bladder Type Before
After
Pyelocaliectasis (rt./ It.)
Before
After
Before
After
0/0 1/1 1/0 0/2 1/1 0/0 0/0 0/0 0/0 0/1 0/0
1/1 1/1 1/1 2/3 1/1 0/0 1/1 1/1 1/1 l+/1+ 0/0
0/1 1/0 0/0 0/2 1/1 0/0 1/0 0/0 0/0 1/0 0/0
0/1 1/0 0/0 1/3 2/1 0/0 2/2 0/0 1/1 l+/0 0/0
1/1 0/0 0/0 1/1
1/1 0/0 1/1 1/1
1/1 0/0 0/0 0/0
1/1 0/0 0/0 0/0
0/0 0/0 2/2 0/1 0/0 1/1
0/0 1/1 2/2 0/1 0/0 1/1
0/0 0/0 1/1 1/0 1/0 1/1
0/0 0/0 1/1 1/0 1/0 1/1
Group I -iced contra..st medium 1 2 3 4
5 6
7 8 9 11
14
Upper Upper Upper Upper Upper Lower Upper Upper Upper Upper Lower
motor motor motor motor motor motor motor motor motor motor motor
neuron neuron neuron neuron neuron neuron neuron neuron neuron neuron neuron
0 0 0 1
1 2
0
3
0 0 0 0
1 2 3
Not available 1
2 2 1
Group 2-room temperature contrast medium 13 14 15 16
Lower Lower Upper Upper
motor motor motor motor
neuron neuron neuron neuron
2 1 0 0
1 1 0 0
Group 3-catheter traction 8 9
10 11
12 13
Upper Upper Upper Upper Upper Lower
motor motor motor motor motor motor
neuron neuron neuron neuron neuron neuron
0 0 0 Not available Not available 1
Not available 1 0
2 2
2
Grading of trabeculation. ureterectasis and pyelocaliectasis: 0-absent, 1-minimal, 2-moderate and 3-severe.
80
STOVER AND ASSOCIATES
FIG. 1. Studies of 17-year-old man with C5 quadriplegia. Radiographs A to C were done on same day with cystogram preceding IVP. A, cystogram before IVP shows contracted, trabeculated bladder. B, 5-minute film of IVP following cystogram shows dilatation of ureters. C, 10minute film following cystogram shows bilateral grade 2 pyelocaliectasis. D, subsequent normal IVP 7 weeks later without intervening therapy.
contraction but rarely was severe enough to cause ureterectasis; pyelocaliectasis was not observed. We acknowledge that iced contrast material is not used routinely for cystography. However, it was used in this study to induce exaggerated reflex changes that would allow the effects of bladder hyperreflexia on the upper and lower urinary tract to be studied. The use of iced contrast material elicited lower and upper tract changes, sometimes marked, in many patients. Of 11 patients who had no evidence of ureterectasis before bladder filling with iced contrast material 7 exhibited ureterectasis subsequent to instillation of iced contrast material during cystography. Five of 11 patients suffered from an increase in pyelocaliectasis during the procedure. Most but not all of the patients with iatrogenic ureterectasis also had iatrogenic pyelocaliectasis. Patients 5 and 8, with marked bladder changes after instillation of iced contrast material, had only minimal changes in the upper tracts. Likewise, patients 4 and
7, who exhibited moderate upper tract changes subsequent to bladder filling with iced contrast material, had modest concurrent bladder changes. Thus, it appears that these artificial bladder and upper tract changes are related. Our findings of bladder changes induced by use of cold contrast material corroborate previous reports from other researchers. 4 •5 The lower urinary tract also may be influenced by technical factors, such as the type of contrast medium used. 2• 6 However, only minimal bladder or upper tract changes were seen in our patients during catheter traction. Since bladder and ureteral dynamics are associated closely in persons with normal innervation of the urinary tract, it is not surprising that the upper urinary tracts of these patients exhibited changes resulting from changes occurring in over-all bladder dynamics. This is especially true when bladder dynamics are exaggerated by increased reflex activity, such as that typically associated with upper motor neuron lesions.
IATROGENIC RADIOGRAPHIC URINARY TRACT ABNORJMALITIES AFTER SPINAL CORD INJUR':'
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FIG. 2. Studies of 19-year-old man with C4 quadriplegia. A, baseline IVP. B, introduction of iced contrast medium into bladder shows contraction and trabeculation of bladder with apparent obstruction at vesicoureteral junction. C, dilatation of ureter and calices after iced contrast medium.
Many independent investigators have presented data to support this hypothesis. Davis and associates studied a series of patients with vesicoureteral reflux and demonstrated that resting ureteral pressure and contractility were affected by changes in bladder pressure and volume. 7 Subsequent studies also demonstrated this relationship in patients without reflux. 8 Voluntary retention of urine in normal children occasionally produces ureteral dilatation and in some cases simulates hydronephrosis. 9· 10 Indeed, this technique has been used to enhance delineation of the pelviocaliceal system and ureters in children11 and adults. 12 Consistent bladder volumes in excess of 375 cc may increase the dimensions and filling of the upper urinary tract to the point of being considered pathological dilatation. 13 Bladder distension may cause a decrease in the renal excretory clearance of urea and, to a lesser extent, the clearance of creatinine.13 The degree of filling of the upper tract also is influenced by the status of hydration, diuresis, and the extent of pathological obstruction. 14- 16 Bladder distension also may alter ureteral peristalsis as well as ureteral dimension. We observed that bladder spasms constrict the flow of urine from the distal ureter into the bladder at the intramural ureter, causing ureterectasis and pyelocaliectasis. Trigonal stretching during bladder filling may attenuate and narrow the intramural ureter, resulting in a physiological ureteral obstruction. 17 Studies in dogs have shown an increase in the amplitude and frequency of ureteral peristalsis with a full bladder. 18• 19 However, this compensating increase inureteral peristalsis eventually is overcome and the ureters eventually distend with a higher resting pressure. 17 Recognizing the fact that multiple factors may be responsible for the phenomenon observed in our study, we hypothesize that the bladder spasms, from whatever cause, seen in spinal cord injury patients with upper motor neuron lesions may lead to vesicoureteral obstruction. This lack of urine transport through the ureters gives the appearance of ureteral and caliceal distension during an IVP. Our findings also suggest that patients with upper motor neuron lesions who experience severe bladder spasms may suffer intermittent obstruction similar to those precipitated by radiographic procedures. It is possible that a patient with increased external sphincter tone and detrusor-sphincter dyssynergia may have an intermittent or chronic increase in the intravesical pressure and coexistent bladder spasms, both of which may impede ureterovesical flow and lead to hydronephrosis. Resistance to ureteral emptying may have implications related to chronic urinary tract infection, impaired renal function and/or urolithiasis.
We believe that our findings dictate caution in the interpretation of contemporaneous IVPs and cystograms, and observe the following guidelines in our clinic. 1) A cystogram should not be performed immediately before an IVP in patients with neurogenic bladders. However, if this sequence cannot be avoided because of the need to evaluate for possible vesicoureteral reflux, an adequate recovery period of at least 1 hour should be allowed between the 2 procedures. 2) The bladder should be emptied completely before an IVP is performed. 3) Cystogram contrast material should be at room or body temperature to avoid inducing artificial changes in bladder configuration. Additional studies are needed to determine whether bladder spasms are capable of creating vesicoureteral obstructions of sufficient magnitude and severity to impair ureteral emptying to a clinically significant degree. REFERENCES
1. Govan, D. E. and Engelsgjerd, G. L.: A method of cystometry to
2. 3. 4. 5,
6. 7. 8. 9. 10.
record bladder activity in neurogenic dysfunction. Arch. Phys. Med., 49: 21, 1968. Scher, A. T.: An evaluation of discrepancy in capacity and contour of the neurogenic bladder as shown on cystography and pyelography. Paraplegia, 17: 358, 1979. Krane, R. J. and Siroky, M. B.: Classification of neuro-urologic disorders. In: Clinical Neuro-Urology. Boston: Little, Brown & Co., chapt. 9, 143, 1979. Rhodes, D. W., M. R and Morrow, J, VV.: Use of the iced cystogram to differentiate bladder neck and external sphincter obstruction. J. UI"OI., 119: 639, 1978. Pearman, J. W., Low, A. L and Fisher, A. A,: The "iced cystogram" -a new technique for distinguishing obstruction at the level of the external sphincter from obstruction at the bladder neck. Paraplegia, 12: 153, 1974. McAlister, W. H., Shackelford, G. D. and Kissane, J.: The histologic effects of 30 percent Cystokon, Hypaque 25 percent and Renografin-30 in the bladder. Radiology, 104: 563, 1972. Davis, D. M., Zimskind, P. D. and Paquet, J.-P.: Studies on urodynamics: new light on ureteral function. J. Urol., 90: 150, 1963. Zimskind, P. D.: The influence of bladder dynamics on ureteral dynamics. In: Urodynamics. Edited by W. Lutzeyer and H. Melchior. New York: Springer-Verlag, p. 154, 1973. Nogrady, M. B., Dunbar, J. S. and MacEwan, D. W.: The effect of (voluntary) bladder distention on the intravenous pyelogram: an experimental study. Amer. J. Roentgen., 90: 37, 1963. Berdon, W. E. and Baker, D. H.: The significance of a distended bladder in the interpretation of intravenous pyelograms obtained on patients with "hydronephrosis". Amer. J. Roentgen., 120: 402, 1974.
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11. Pajewski, M. and Manor, A.: Enhanced intravenous urography in infants and children produced by distension of the urinary bladder. Clin. Rad., 24: 376, 1973. 12. Pajewski, M., Manor, A. and Gil, I.: Diagnostic value of distended urinary bladder pyelography in adults. Isr. J. Med. Sci., 18: 854, 1982. 13. Gill, W. B. and Curtis, G. A.: The influence of bladder fullness on upper urinary tract dimensions and renal excretory function. J. Urol., 11 7: 573, 1977. 14. Boyarsky, S.: Urodynamic studies. In: Diagnostic Urology. Edited by J. Glenn. New York: Harper & Row Publishers, Inc., chapt. 6, p. 126, 1964. 15. Emmett, J. L.: Clinical Urography, 2nd ed. Philadelphia: W. B. Saunders Co., 1964.
16. Friedenberg, R. M.: Radiographic examination of the ureter. In: The Ureter. Edited by H. Bergman. New York: Harper & Row Publishers, Inc., chapt. 9, p. 188, 1967. 17. Tanagho, E. A., Hutch, J. A., Meyers, F. H. and Rambo, 0. N., Jr.: Primary vesicoureteral reflux: experimental studies of its etiology. J. Urol., 93: 165, 1965. 18. Anderson, G. F., Pierce, J. M., Jr. and Fredericks, C. M.: The ureteral response to bladder filling. In: Urodynamics: Hydrodynamics of the Ureter and Renal Pelvis. Edited by S. Boyarsky, C. W. Gottshalk, E. A. Tanagho and P. D. Zimskind. New York: Academic Press, Inc., chapt. 21, p. 283, 1971. 19. Rosen, D. I., Constantinou, C. E., Sands, J.P. and Govan, D. E.: Dynamics of the upper urinary tract: effects of changes in bladder pressure on ureteral peristalsis. J. Urol., 106: 209, 1971.