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MICTURITION AND DEFECATION: WHICH ACT HAS PREDOMINANCE?
957
958
CLINICAL AND URODYNAMIC ABNORMALITIES OF PATIENTS IN DIFFERENT PHASES AFTER CEREBROVASCULAR ACCIDENTS Abdel Hafez A.1, Rohrmann D.2, Toepper R.3, Noth J.3, Jakse G.2 1 Faculty of Medicine, Urology Department, Sohag, Egypt, 2Klinikum der RWTH, Aachen, Urology Department, Aachen, Germany, 3Klinikum der RWTH, Aachen, Neurology Department, Aachen, Germany INTRODUCTION & OBJECTIVES: The bladder receives innervation from both pyramidal tracts, so it was thought that bladder function is not affected in strokes which are unilateral lesion. It was however observed that many patients develop Lower Urinary tract Symptoms (LUTS) and incontinence in addition to urodynamic abnormalities after stroke. Our aim was to identify the clinical as well as the urodynamic abnormalities in these patients in different phases and as early as possible after stroke. MATERIAL & METHODS: A total of 44 males and 16 females were prospectively examined clinically and urodynamically in different phases and as early as 2 days after stroke. RESULTS: Clinically: irritative LUTS were the commonest, followed by obstructive LUTS. There was no identifiable shock stage even in the patients who were examined as early as 2 days after stroke. Urodynamically, detrusor hyperreflexia was the commonest finding (19 patients) followed by hyporeflexia (8 patients). Pseudo-dyssynergia or uninhibited sphincter relaxation (USR) were observed, but true detrusor-sphincter dyssynergia (DSD) and upper tract deterioration were not encountered in our series. CONCLUSIONS: 1-Strokes are not without effect on the urinary tract. Detrusor hyperreflexia is the commonest urodynamic abnormality followed by hyporeflexia. The sphincter may show pseudo-dyssynergia or USR but no DSD. 2-The urodynamic findings were affected by already-present or subsequently issuing diseases such as BPH or age-related changes. 3-The reason why some lesions produced hyperreflexia, some produced hyporeflexia and others were without effect remains to be answered. The optimal understanding of the problem is dependent upon the better understanding of the function of every part of the brain which is not yet clarified. In this regard, it is of value to stress that correlation between urodynamic, CT and Positron Emission Tomography (PET) findings will be of utmost value in understanding and managing the problem. Also, late follow up of the patients should be undertaken to understand the long-term outcome of stroke. We recommend further in-depth studies in these directions.
URODYNAMICALLY DEMONSTRATED RECTAL CONTRACTIONS: DO THEY REPRESENT NEUROPATHY? Abdel Hafez A.1, Rohrmann D.2, Jakse G.2 1 Faculty of Medicine, Dept. of Urology, Sohag, Egypt, 2Faculty of Medicine, Dept. of Urology, Aachen, Germany
INTRODUCTION & OBJECTIVES: Independent rectal contractions are sometimes encountered during multi channel urodynamic examination. They are always regarded as an incidental finding or an artifact; this is in contrast to bladder contractions which are always considered significant and pathological. Our aim was to study the prevalence of rectal contractions and whether they particularly prevalent in patients with neurologic diseases. MATERIAL & METHODS: The urodynamic tracings of 200 patients were retrospectively reviewed and analysed for the presence of rectal contractions. One hundred patients had evident neurologic diseases (cerebrovascular accidents, parkinsonism, parkinsonism, cord transaction cauda equine lesions etc.). Rectal contractions were defined as a rise of rectal pressure more than 5 cm water not associated with rise of intravesical pressure and associated with negative deflection of detrusor pressure. RESULTS: Rectal contractions were found in 49% of patients with neurologic diseases and in only 21%of those with non neurogenic voiding dysfunction. In patients with neurogenic diseases, rectal contractions correlated to detrusor hyperreflexia. Rectal Contractions were classified into 2 groups: rhythmic and random, and each of these was classified into low amplitude (< 15 cm water) and high amplitude (>15 cm water). CONCLUSIONS: Rectal contractions seem to be neither an incidental finding nor an artifact. They are particular prevalent in patients with neurologic disease and are highly correlated with detrusor hyperreflexia which may reflect similar innervation. They are also prevalent in non-neurologic voiding dysfunction which may reflect a pelvic floor dysfunction. Further prospective controlled studies are needed to clarify the real significance of this phenomenon.
959
960
GUARDING RESPONSE OF THE BLADDER AND BOWEL: ARE THEY BOTH ABERRANT FOLLOWING SPINAL CORD INJURY?
MICTURITION AND PREDOMINANCE?
DEFECATION:
WHICH
ACT
HAS
Balasubramaniam A.V.1, Chung E.A.L.2, Woodhouse J.B.3, Craggs M.D.4, Knight S.L.3, Bycroft J.A.3, Gall A.5, Middleton F.R.I.5
De Wachter S., Wyndaele J.J.
1
Royal National Orthopaedic Hospital & Institute of Urology and Nephrology, Spinal Research Centre, Stanmore, United Kingdom, 2St. Marks Hospital, Harrow ; Royal National Orthopaedic Hospital, Spinal Research Centre, Stanmore, United Kingdom, 3Royal National Orthopaedic Hospital, Spinal Research Centre, Stanmore, United Kingdom, 4Royal National Orthopaedic Hospital; Institute of Urology & Nephrology, University College Londo, Spinal Research Centre, Stanmore, United Kingdom, 5Royal National Orthopaedic Hospital, Rehabilitation, Stanmore, United Kingdom
INTRODUCTION & OBJECTIVES: It has been shown previously that if bladder and rectum are simultaneously distended, perception of bladder sensation takes priority over perception of rectal sensation (Neurourol urodyn 24(5), 537, 2005). This study evaluates whether such a predominance exists between micturition and defecation.
INTRODUCTION & OBJECTIVES: Supra-sacral spinal cord injury (SCI) causes serious disruption to the function of the bladder and the bowel. The urinary guarding response (GR, as measured by the pudendo-anal reflex (PAR) response), which changes with neurological intactness, acts to maintain bladder continence, by allowing good bladder-urethral sphincter coordination. Aim: To investigate whether SCI brings about a similar state of aberrance of the GR in the bowel.
RESULTS: A total of 500 events were observed. Mean scores for rectal and bladder fullness on the VAG scale respectively were 6.8 ± 2.3 and 3.8 ± 3.0. Sixty defecations occurred without while 440 occurred with micturition. Although the rectal fullness score was not different between both groups (p=0.39), bladder fullness was significantly less in the group without defecation, respectively 0.5 ± 0.9 vs. 4.3 ± 2.9 (p<0.0001). In 14 events (3.2%) micturition and defecation started at the same time, micturition started before defecation in 267 events (60.7%), while defecation started before micturition in 159 (36.1%). Data on the sequence of micturition and defecation according to the perception of bladder and rectal fullness are presented in graph 1.
University of Antwerpen, Urology, Wilrijk, Belgium
MATERIAL & METHODS: One hundred healthy volunteers (24 men and 76 women, mean age 24 ±7 years) graded both bladder and rectal fullness on a visual analog scale (VAG scale) when they went to the toilet with the intention to defecate. They also reported whether micturition started before, simultaneously with or after defecation. Each volunteer reported on 5 such events.
MATERIAL & METHODS: Local ethics committee approval and fully informed consent was obtained. The PAR was elicited using dorsal penile nerve transcutaneous electrical stimulation. The amplitude of the PAR was recorded using an intra-anal plug electrode (Anuform©, NeenHealth). Standard urodynamics were used for bladder filling. Rectal filling was achieved utilising a Barostat machine (Distender Series II, G&J Electronics). The PAR at bladder and rectal end-fill-volumes (PARbefv, PARrefv) were recorded. The results were normalised to the PAR recorded with an empty bladder or rectum. RESULTS: PARbefv responses in complete SCI subjects were significantly smaller than non-SCI subjects (**p<0.005). Data from incomplete SCI were comparable to non-SCI responses. In the case of the rectum, PARrefv were comparable between groups. PARrefv was significantly different (# p=0.01) from PARbefv in complete SCI subjects. At low grades of bladder fullness, defecation occurs more frequently before micturition. However at score 4 of bladder fullness, the order changes and the higher the grade of bladder fullness, the higher the percentage of events at which micturition occurs before defecation. At low grades of rectal fullness, micturition occurs more frequently before defecation. Only if rectal fullness is graded 9 or 10, the order is reversed and defecation more frequently occurs before micturition. Graph 2 presents the data if VAG scores for bladder and rectal fullness at each event are compared to each other.
CONCLUSIONS: Unlike the urinary GR, the rectal GR appears to be unaffected by SCI. This might suggest a greater role for supra-spinal pathways on lower urinary tract coordination than on the lower bowel. Clinical Implication: The integrity of the urinary GR may be used as part of a grading system for autonomic function following injury so that we can better determine the outcome of new interventions such as neural repair on the restoration of coordinated function of the bladder and sphincters.
Eur Urol Suppl 2006;5(2):262
When the bladder is considered equally full or more full than the rectum, micturition precedes defecation in the vast majority of events. Even when the rectum is considered more full than the bladder, micturition still precedes defecation in almost half of the events. CONCLUSIONS: This observational study shows that there exists a sequence in the acts of micturition and defecation. Micturition seems to be predominant to defecation.
958
CLINICAL AND URODYNAMIC ABNORMALITIES OF PATIENTS IN DIFFERENT PHASES AFTER CEREBROVASCULAR ACCIDENTS Abdel Hafez A.1, Rohrmann D.2, Toepper R.3, Noth J.3, Jakse G.2 1 Faculty of Medicine, Urology Department, Sohag, Egypt, 2Klinikum der RWTH, Aachen, Urology Department, Aachen, Germany, 3Klinikum der RWTH, Aachen, Neurology Department, Aachen, Germany INTRODUCTION & OBJECTIVES: The bladder receives innervation from both pyramidal tracts, so it was thought that bladder function is not affected in strokes which are unilateral lesion. It was however observed that many patients develop Lower Urinary tract Symptoms (LUTS) and incontinence in addition to urodynamic abnormalities after stroke. Our aim was to identify the clinical as well as the urodynamic abnormalities in these patients in different phases and as early as possible after stroke. MATERIAL & METHODS: A total of 44 males and 16 females were prospectively examined clinically and urodynamically in different phases and as early as 2 days after stroke. RESULTS: Clinically: irritative LUTS were the commonest, followed by obstructive LUTS. There was no identifiable shock stage even in the patients who were examined as early as 2 days after stroke. Urodynamically, detrusor hyperreflexia was the commonest finding (19 patients) followed by hyporeflexia (8 patients). Pseudo-dyssynergia or uninhibited sphincter relaxation (USR) were observed, but true detrusor-sphincter dyssynergia (DSD) and upper tract deterioration were not encountered in our series. CONCLUSIONS: 1-Strokes are not without effect on the urinary tract. Detrusor hyperreflexia is the commonest urodynamic abnormality followed by hyporeflexia. The sphincter may show pseudo-dyssynergia or USR but no DSD. 2-The urodynamic findings were affected by already-present or subsequently issuing diseases such as BPH or age-related changes. 3-The reason why some lesions produced hyperreflexia, some produced hyporeflexia and others were without effect remains to be answered. The optimal understanding of the problem is dependent upon the better understanding of the function of every part of the brain which is not yet clarified. In this regard, it is of value to stress that correlation between urodynamic, CT and Positron Emission Tomography (PET) findings will be of utmost value in understanding and managing the problem. Also, late follow up of the patients should be undertaken to understand the long-term outcome of stroke. We recommend further in-depth studies in these directions.
URODYNAMICALLY DEMONSTRATED RECTAL CONTRACTIONS: DO THEY REPRESENT NEUROPATHY? Abdel Hafez A.1, Rohrmann D.2, Jakse G.2 1 Faculty of Medicine, Dept. of Urology, Sohag, Egypt, 2Faculty of Medicine, Dept. of Urology, Aachen, Germany
INTRODUCTION & OBJECTIVES: Independent rectal contractions are sometimes encountered during multi channel urodynamic examination. They are always regarded as an incidental finding or an artifact; this is in contrast to bladder contractions which are always considered significant and pathological. Our aim was to study the prevalence of rectal contractions and whether they particularly prevalent in patients with neurologic diseases. MATERIAL & METHODS: The urodynamic tracings of 200 patients were retrospectively reviewed and analysed for the presence of rectal contractions. One hundred patients had evident neurologic diseases (cerebrovascular accidents, parkinsonism, parkinsonism, cord transaction cauda equine lesions etc.). Rectal contractions were defined as a rise of rectal pressure more than 5 cm water not associated with rise of intravesical pressure and associated with negative deflection of detrusor pressure. RESULTS: Rectal contractions were found in 49% of patients with neurologic diseases and in only 21%of those with non neurogenic voiding dysfunction. In patients with neurogenic diseases, rectal contractions correlated to detrusor hyperreflexia. Rectal Contractions were classified into 2 groups: rhythmic and random, and each of these was classified into low amplitude (< 15 cm water) and high amplitude (>15 cm water). CONCLUSIONS: Rectal contractions seem to be neither an incidental finding nor an artifact. They are particular prevalent in patients with neurologic disease and are highly correlated with detrusor hyperreflexia which may reflect similar innervation. They are also prevalent in non-neurologic voiding dysfunction which may reflect a pelvic floor dysfunction. Further prospective controlled studies are needed to clarify the real significance of this phenomenon.
959
960
GUARDING RESPONSE OF THE BLADDER AND BOWEL: ARE THEY BOTH ABERRANT FOLLOWING SPINAL CORD INJURY?
MICTURITION AND PREDOMINANCE?
DEFECATION:
WHICH
ACT
HAS
Balasubramaniam A.V.1, Chung E.A.L.2, Woodhouse J.B.3, Craggs M.D.4, Knight S.L.3, Bycroft J.A.3, Gall A.5, Middleton F.R.I.5
De Wachter S., Wyndaele J.J.
1
Royal National Orthopaedic Hospital & Institute of Urology and Nephrology, Spinal Research Centre, Stanmore, United Kingdom, 2St. Marks Hospital, Harrow ; Royal National Orthopaedic Hospital, Spinal Research Centre, Stanmore, United Kingdom, 3Royal National Orthopaedic Hospital, Spinal Research Centre, Stanmore, United Kingdom, 4Royal National Orthopaedic Hospital; Institute of Urology & Nephrology, University College Londo, Spinal Research Centre, Stanmore, United Kingdom, 5Royal National Orthopaedic Hospital, Rehabilitation, Stanmore, United Kingdom
INTRODUCTION & OBJECTIVES: It has been shown previously that if bladder and rectum are simultaneously distended, perception of bladder sensation takes priority over perception of rectal sensation (Neurourol urodyn 24(5), 537, 2005). This study evaluates whether such a predominance exists between micturition and defecation.
INTRODUCTION & OBJECTIVES: Supra-sacral spinal cord injury (SCI) causes serious disruption to the function of the bladder and the bowel. The urinary guarding response (GR, as measured by the pudendo-anal reflex (PAR) response), which changes with neurological intactness, acts to maintain bladder continence, by allowing good bladder-urethral sphincter coordination. Aim: To investigate whether SCI brings about a similar state of aberrance of the GR in the bowel.
RESULTS: A total of 500 events were observed. Mean scores for rectal and bladder fullness on the VAG scale respectively were 6.8 ± 2.3 and 3.8 ± 3.0. Sixty defecations occurred without while 440 occurred with micturition. Although the rectal fullness score was not different between both groups (p=0.39), bladder fullness was significantly less in the group without defecation, respectively 0.5 ± 0.9 vs. 4.3 ± 2.9 (p<0.0001). In 14 events (3.2%) micturition and defecation started at the same time, micturition started before defecation in 267 events (60.7%), while defecation started before micturition in 159 (36.1%). Data on the sequence of micturition and defecation according to the perception of bladder and rectal fullness are presented in graph 1.
University of Antwerpen, Urology, Wilrijk, Belgium
MATERIAL & METHODS: One hundred healthy volunteers (24 men and 76 women, mean age 24 ±7 years) graded both bladder and rectal fullness on a visual analog scale (VAG scale) when they went to the toilet with the intention to defecate. They also reported whether micturition started before, simultaneously with or after defecation. Each volunteer reported on 5 such events.
MATERIAL & METHODS: Local ethics committee approval and fully informed consent was obtained. The PAR was elicited using dorsal penile nerve transcutaneous electrical stimulation. The amplitude of the PAR was recorded using an intra-anal plug electrode (Anuform©, NeenHealth). Standard urodynamics were used for bladder filling. Rectal filling was achieved utilising a Barostat machine (Distender Series II, G&J Electronics). The PAR at bladder and rectal end-fill-volumes (PARbefv, PARrefv) were recorded. The results were normalised to the PAR recorded with an empty bladder or rectum. RESULTS: PARbefv responses in complete SCI subjects were significantly smaller than non-SCI subjects (**p<0.005). Data from incomplete SCI were comparable to non-SCI responses. In the case of the rectum, PARrefv were comparable between groups. PARrefv was significantly different (# p=0.01) from PARbefv in complete SCI subjects. At low grades of bladder fullness, defecation occurs more frequently before micturition. However at score 4 of bladder fullness, the order changes and the higher the grade of bladder fullness, the higher the percentage of events at which micturition occurs before defecation. At low grades of rectal fullness, micturition occurs more frequently before defecation. Only if rectal fullness is graded 9 or 10, the order is reversed and defecation more frequently occurs before micturition. Graph 2 presents the data if VAG scores for bladder and rectal fullness at each event are compared to each other.
CONCLUSIONS: Unlike the urinary GR, the rectal GR appears to be unaffected by SCI. This might suggest a greater role for supra-spinal pathways on lower urinary tract coordination than on the lower bowel. Clinical Implication: The integrity of the urinary GR may be used as part of a grading system for autonomic function following injury so that we can better determine the outcome of new interventions such as neural repair on the restoration of coordinated function of the bladder and sphincters.
Eur Urol Suppl 2006;5(2):262
When the bladder is considered equally full or more full than the rectum, micturition precedes defecation in the vast majority of events. Even when the rectum is considered more full than the bladder, micturition still precedes defecation in almost half of the events. CONCLUSIONS: This observational study shows that there exists a sequence in the acts of micturition and defecation. Micturition seems to be predominant to defecation.