- Email: [email protected]
Management of Upper Urinary Tract Complications in Multiple Sclerosis by Means of Urinary Diversion to an Ileal Conduit
Vol. 93, May
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
Printed in U.S.A.
MANAGEMENT OF UPPER URINARY TRACT COMPLICATIONS IN MULTIPLE SCLEROSIS BY MEANS OF URINARY DIVERSION TO AN ILEAL CONDUIT WILLIAM SAMELLAS
AND
BARRY RUBIN
From the Department of Surgery (Urology), Veterans Administration Hospital, and the State University of New York, Downstate Medical Center, Brooklyn, New York
Multiple sclerosis is not a rare disease, having a 6 to 10 per cent incidence among all other neurological diseases. 1 It affects people between the age of 20 and 40. Since the disease is characterized by plaques of demyelinization scattered throughout the nervous system, it is not surprising that disorders of micturition occur frequently. 2 Proper management of the urological complications is necessary if patient survival is to be insured. Of 165 patients with multiple sclerosis treated in our institution in the past 10 years, the urinary tract was affected in 88 (55 per cent) using as criteria for urological disease precipitous type of voiding, incontinence, and urinary infection with its associated complications. The upper urinary tract was involved in 18 or 19 per cent of the patients. The manifestations varied from pyelonephritis to variable degrees of hydronephrosis. Since all of the patients did not have routine excretory urograms some of them may have had undetected damage of the upper urinary tract. Death in 12 of 20 cases (55 per cent) of multiple sclerosis in which autopsies were performed was ascribed to hydronephrosis, pyelonephritis, and/ or septicemia arising in the urinary tract. Since 55 per cent of the deaths were attributed to disease in the urinary tract, which could have been prevented, efforts were made to improve management of such cases. The patients at an early stage of the disease manifest symptoms of incomplete lesions of the upper motor neuron. The severity of symptomatology depends upon the extent to which the spinal cord is involved. Some patients can initiate voiding in a relatively normal fashion, but most of them exhibit precipitous micturition, i.e. an uncontrollable urge to void which results in incontinence due to urgency. Inhibition of micturiAccepted for publication October 2, 1964. 1 Alpers, B. J.: Clinical Neurology. Philadelphia: F. A. Davis Co., 1963. • Talbot, H. S.: Care of the bladder in neurological disorders. J.A.M.A., 161: 944, 1956.
tion is also impaired. These patients are unable to utilize the levator ani and external sphincter muscles as normal people do. As a result, they cannot inhibit the detrusor from emptying the bladder and consequently suffer from involuntary loss of urine.
Fm. 1. Urethral diverticula. Patient penile clamp to control incontinence.
used
Detrusor hyperirritability is another important factor. In addition, the sudden contractions of the detrusor muscle which result from sudden increase of the intra-abdominal pressure further contribute to micturition and urinary frequency. Hyper-irritability causes an increase in intravesical pressure and a diminution in bladder capacity. The therapeutic objectives are directed toward the reduction of vesical irritability, the elimination of extravesical stimuli and the lowering of intravesical pressure. In our experience the use of anticholinergic drugs such as banthine and probanthine failed to successfully control bladder ir548
URINARY DIVERSION IN PATIENTS WITH MULTIPLE SCLEROSIS
549
FIG. 2. A, excretory urogram shows bilateral hydronephrosis and hydroureter. B, normal upper urinary tracts, a year later, following diversion of urine to ilea! conduit. ritability and urinary urgency; others have been more encouraging in their evaluations. 3 Neurogenic disorders of the bladder are prone to develop infection spontaneously. Cystitis becomes chronic and should be vigorously treated with antibiotics since it contributes to bladder irritability. In a few cases, transurethral resection of the bladder neck was carried out to eliminate residual urine. The improved voiding may make existing incontinence more apparent. This occurred in 3 instances. Others have reported about 50 per cent good results in patients having a substantial amount of residual by means of transurethral resection of bladder neck, 4 - 5 Prostatic 3 Muellner, S. R.: Control of urinary incontinence in patients with multiple sclerosis. J.A.M.A., 154: 975, 1954. 4 Emmett, J. L., Albers, D. D. and Anderson, R. E.: Statistical and analytic review of the final results of trans urethral resection for cord bladder. J. Urol., 65: 36, 1951. 5 Baker, W. J., Carney, J. F. and DeRosa, F. P.: Transurethral resection for relief of urinary retention in patients with neurological lesions. J. Urol., 63: 309, 1950.
obstruction had not been a significant cause of residual urine in this group of young patients. Increased intravesical pressure can be reduced by means of catheter or suprapubic drainage. However, these measures fail to alter the pathologic changes in the bladder wall, i.e. hypertrophy of the detrusor, trabeculations and cellule formation, which result from repetitive nervous impulses that arise in a hyperactive spinal cord. The cystoscopie appearance of the bladder is familiar to all who have treated multiple sclerosis. Consequent to these changes in the bladder some patients will have either reflux or obstruction at the level of the ureterovesical junction, resulting in hydrometer and hydronephrosis. The detrimental effect of reflux on the kidney, especially in neurogenic bladders, is well documented to warrant comment. 6 - 7 Correction of this 6 Talbot, H. S. and Bunts, R. C.: Late renal changes in paraplegia: Hydronephrosis due to vesicoureteral reflux. J. Urol., 61: 870, 1949. 7 Hutch, J. A.: Vesicoureteral reflux in the
550
SAMELLAS AND RUBIN
FIG. 3. A, bilateral reflux. B, normal upper urinary tract 6 months after surgery
situation is imperative especially when upper urinary tract changes are associated with chills and fever. Conservative therapy such as catheter drainage, antibiotics and anticholinergic drugs should be tried before undertaking surgical treatment. If these measures fail to halt further changes in the upper urinary tract, diversion of the urine becomes necessary. Ureterovesical procedures to correct reflux or eliminate obstruction at the vesical level are doomed to failure because the bladder is already diseased and the factors which were responsible for the development of obstruction or reflux are still present. Due to its decreased capacity, the bladder ceases to function as a reservoir and becomes the site of infection which adds to bladder irritability. The use of penile clamps, by some of the patients, to control incontinence may result in necrosis of the skin and urethral diverticula (fig. 1). paraplegic; cause and correction. J. Urol., 68: 457, 1952.
Ureterosigmoidostomy is exc.luded because of the upper urinary tract damage and disturbance of function of rectal sphincter. Cutaneous ureterostomy and nephrostomy may result in further damage to the kidneys due to the persistence of infection, frequent changes of the tubes, and calculus formation. Therefore, the diversion of urine to an ileal conduit is the procedure of choice. Urinary diversion to an ileal conduit was performed in 8 patients who had reflux or obstruction at the ureterovesical junction. All patients had previously been treated by conservative means which failed to correct the condition. In all cases, the improvement in the upper urinary tract was remarkable. The infection subsided and the patients gained weight. They were pleased with the new arrangement and their morale improved. After the urine has been diverted, the bladder may require irrigations with an antiseptic solution to prevent infection from retained secretions. Such was the case in one patient necessitating cystectomy.
URINARY DIVERSION IN PATIENTS WITH MULTIPLE SCLEROSIS
551
Fm. 4. A, blunting of calyces and hydroureter on left side. Note obstruction of ureters at vesical level. Bladder is markedly trabeculated and contracted. B, excretory urogram appears normal 3 months after diverting urine. CASE SUMMARIES
Case 1. L. D., A-6929, a 34-year-old white man, had had multiple sclerosis for 10 years. For the past 2 years, he was unable to control his urine. He had severe cystitis and episodes of flank pain associated with chills and fever. Cultures of urine grew Escherichia coli, Pseudomonas aeruginosa and Bacillus proteus. Excretory urography disclosed bilateral hydronephrosis and hydroureter (fig. 2, A). The ureters appeared to be obstructed at the bladder level. Cystoscopy revealed diminished bladder capacity, marked trabeculation and infection. Since catheter drainage and antibiotics failed to improve the condition, urinary diversion to an ileal conduit was performed without incident. The urinary infection subsided and the upper urinary tracts were restored to normal (fig. 2, B). Case 2. P. S., A-1553, a 35-year-old white man,
entered the hospital because of symptoms of multiple sclerosis of 6 years' duration. He had frequency and incontinence due to severe urgency. Probanthine, 15 mg. 4 times a day, failed to control urinary urgency. The bladder neck was resected transurethrally because of 50 to 80 cc residual urine on several occasions. When the catheter was removed the patient was able to void with a better stream. The urinary incontinence did not improve. Six months later the patient had vesicoureteral reflux (fig. 3, A) associated with bouts of chills and fever. Catheter drainage and treatment with antibiotics failed to halt reflux. Urinary diversion to an ileal conduit was performed and the postoperative course was uneventful. The patient has been free of infection and the hydronephrosis has subsided (fig. 3, B). Case 3. V. F., A-21497, a 40-year-old white
man, had had multiple sclerosis for 6 years and
552
SAMELLAS AND RUBIN
urinary frequency day and night for the past 3 years. The voiding volume ranged between 15 and 60 cc and involuntary loss of urine was a constant complaint. Excretory urography disclosed moderate left hydronephrosis and hydroureter with blunting of the calyces (fig. 4, A). Both ureters were seen cut off at the bladder level. The bladder appeared markedly trabeculated with diminished capacity. A suprapubic cystostomy was performed elsewhere because of bleeding from severe hemorrhagic cystitis. Anticholinergic drugs and antibiotics were ineffective. The patient also had bouts of flank pain associated with chills and fever. Urinary diversion to an ileal conduit was performed uneventfully. The infection, hydronephrosis, and blunting of calyces have subsided (fig. 4, B). There is an erroneous conception that patients with multiple sclerosis are poor surgical risks. All patients withstood surgery and anesthesia with-
out incident and behaved similar to any other patient. Urinary diversion should be performed as soon as progressive upper urinary tract changes develop and before irreversible da1nage occurs in the kidneys. Our results are encouraging. By preserving renal function, one of the main causes of death is eliminated and life becomes more comfortable for the patient. SUMMARY
The urinary tract was involved in 55 per cent of the cases in a study of 165 patients with multiple sclerosis. Urologic disease was attributed as the main cause of death in half of the cases. Urinary diversion to an ileal conduit is the procedure of choice when progressive upper urinary tract changes develop. Infection was eliminated, the upper urinary tracts were restored to normal and renal function was preserved.
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
Printed in U.S.A.
MANAGEMENT OF UPPER URINARY TRACT COMPLICATIONS IN MULTIPLE SCLEROSIS BY MEANS OF URINARY DIVERSION TO AN ILEAL CONDUIT WILLIAM SAMELLAS
AND
BARRY RUBIN
From the Department of Surgery (Urology), Veterans Administration Hospital, and the State University of New York, Downstate Medical Center, Brooklyn, New York
Multiple sclerosis is not a rare disease, having a 6 to 10 per cent incidence among all other neurological diseases. 1 It affects people between the age of 20 and 40. Since the disease is characterized by plaques of demyelinization scattered throughout the nervous system, it is not surprising that disorders of micturition occur frequently. 2 Proper management of the urological complications is necessary if patient survival is to be insured. Of 165 patients with multiple sclerosis treated in our institution in the past 10 years, the urinary tract was affected in 88 (55 per cent) using as criteria for urological disease precipitous type of voiding, incontinence, and urinary infection with its associated complications. The upper urinary tract was involved in 18 or 19 per cent of the patients. The manifestations varied from pyelonephritis to variable degrees of hydronephrosis. Since all of the patients did not have routine excretory urograms some of them may have had undetected damage of the upper urinary tract. Death in 12 of 20 cases (55 per cent) of multiple sclerosis in which autopsies were performed was ascribed to hydronephrosis, pyelonephritis, and/ or septicemia arising in the urinary tract. Since 55 per cent of the deaths were attributed to disease in the urinary tract, which could have been prevented, efforts were made to improve management of such cases. The patients at an early stage of the disease manifest symptoms of incomplete lesions of the upper motor neuron. The severity of symptomatology depends upon the extent to which the spinal cord is involved. Some patients can initiate voiding in a relatively normal fashion, but most of them exhibit precipitous micturition, i.e. an uncontrollable urge to void which results in incontinence due to urgency. Inhibition of micturiAccepted for publication October 2, 1964. 1 Alpers, B. J.: Clinical Neurology. Philadelphia: F. A. Davis Co., 1963. • Talbot, H. S.: Care of the bladder in neurological disorders. J.A.M.A., 161: 944, 1956.
tion is also impaired. These patients are unable to utilize the levator ani and external sphincter muscles as normal people do. As a result, they cannot inhibit the detrusor from emptying the bladder and consequently suffer from involuntary loss of urine.
Fm. 1. Urethral diverticula. Patient penile clamp to control incontinence.
used
Detrusor hyperirritability is another important factor. In addition, the sudden contractions of the detrusor muscle which result from sudden increase of the intra-abdominal pressure further contribute to micturition and urinary frequency. Hyper-irritability causes an increase in intravesical pressure and a diminution in bladder capacity. The therapeutic objectives are directed toward the reduction of vesical irritability, the elimination of extravesical stimuli and the lowering of intravesical pressure. In our experience the use of anticholinergic drugs such as banthine and probanthine failed to successfully control bladder ir548
URINARY DIVERSION IN PATIENTS WITH MULTIPLE SCLEROSIS
549
FIG. 2. A, excretory urogram shows bilateral hydronephrosis and hydroureter. B, normal upper urinary tracts, a year later, following diversion of urine to ilea! conduit. ritability and urinary urgency; others have been more encouraging in their evaluations. 3 Neurogenic disorders of the bladder are prone to develop infection spontaneously. Cystitis becomes chronic and should be vigorously treated with antibiotics since it contributes to bladder irritability. In a few cases, transurethral resection of the bladder neck was carried out to eliminate residual urine. The improved voiding may make existing incontinence more apparent. This occurred in 3 instances. Others have reported about 50 per cent good results in patients having a substantial amount of residual by means of transurethral resection of bladder neck, 4 - 5 Prostatic 3 Muellner, S. R.: Control of urinary incontinence in patients with multiple sclerosis. J.A.M.A., 154: 975, 1954. 4 Emmett, J. L., Albers, D. D. and Anderson, R. E.: Statistical and analytic review of the final results of trans urethral resection for cord bladder. J. Urol., 65: 36, 1951. 5 Baker, W. J., Carney, J. F. and DeRosa, F. P.: Transurethral resection for relief of urinary retention in patients with neurological lesions. J. Urol., 63: 309, 1950.
obstruction had not been a significant cause of residual urine in this group of young patients. Increased intravesical pressure can be reduced by means of catheter or suprapubic drainage. However, these measures fail to alter the pathologic changes in the bladder wall, i.e. hypertrophy of the detrusor, trabeculations and cellule formation, which result from repetitive nervous impulses that arise in a hyperactive spinal cord. The cystoscopie appearance of the bladder is familiar to all who have treated multiple sclerosis. Consequent to these changes in the bladder some patients will have either reflux or obstruction at the level of the ureterovesical junction, resulting in hydrometer and hydronephrosis. The detrimental effect of reflux on the kidney, especially in neurogenic bladders, is well documented to warrant comment. 6 - 7 Correction of this 6 Talbot, H. S. and Bunts, R. C.: Late renal changes in paraplegia: Hydronephrosis due to vesicoureteral reflux. J. Urol., 61: 870, 1949. 7 Hutch, J. A.: Vesicoureteral reflux in the
550
SAMELLAS AND RUBIN
FIG. 3. A, bilateral reflux. B, normal upper urinary tract 6 months after surgery
situation is imperative especially when upper urinary tract changes are associated with chills and fever. Conservative therapy such as catheter drainage, antibiotics and anticholinergic drugs should be tried before undertaking surgical treatment. If these measures fail to halt further changes in the upper urinary tract, diversion of the urine becomes necessary. Ureterovesical procedures to correct reflux or eliminate obstruction at the vesical level are doomed to failure because the bladder is already diseased and the factors which were responsible for the development of obstruction or reflux are still present. Due to its decreased capacity, the bladder ceases to function as a reservoir and becomes the site of infection which adds to bladder irritability. The use of penile clamps, by some of the patients, to control incontinence may result in necrosis of the skin and urethral diverticula (fig. 1). paraplegic; cause and correction. J. Urol., 68: 457, 1952.
Ureterosigmoidostomy is exc.luded because of the upper urinary tract damage and disturbance of function of rectal sphincter. Cutaneous ureterostomy and nephrostomy may result in further damage to the kidneys due to the persistence of infection, frequent changes of the tubes, and calculus formation. Therefore, the diversion of urine to an ileal conduit is the procedure of choice. Urinary diversion to an ileal conduit was performed in 8 patients who had reflux or obstruction at the ureterovesical junction. All patients had previously been treated by conservative means which failed to correct the condition. In all cases, the improvement in the upper urinary tract was remarkable. The infection subsided and the patients gained weight. They were pleased with the new arrangement and their morale improved. After the urine has been diverted, the bladder may require irrigations with an antiseptic solution to prevent infection from retained secretions. Such was the case in one patient necessitating cystectomy.
URINARY DIVERSION IN PATIENTS WITH MULTIPLE SCLEROSIS
551
Fm. 4. A, blunting of calyces and hydroureter on left side. Note obstruction of ureters at vesical level. Bladder is markedly trabeculated and contracted. B, excretory urogram appears normal 3 months after diverting urine. CASE SUMMARIES
Case 1. L. D., A-6929, a 34-year-old white man, had had multiple sclerosis for 10 years. For the past 2 years, he was unable to control his urine. He had severe cystitis and episodes of flank pain associated with chills and fever. Cultures of urine grew Escherichia coli, Pseudomonas aeruginosa and Bacillus proteus. Excretory urography disclosed bilateral hydronephrosis and hydroureter (fig. 2, A). The ureters appeared to be obstructed at the bladder level. Cystoscopy revealed diminished bladder capacity, marked trabeculation and infection. Since catheter drainage and antibiotics failed to improve the condition, urinary diversion to an ileal conduit was performed without incident. The urinary infection subsided and the upper urinary tracts were restored to normal (fig. 2, B). Case 2. P. S., A-1553, a 35-year-old white man,
entered the hospital because of symptoms of multiple sclerosis of 6 years' duration. He had frequency and incontinence due to severe urgency. Probanthine, 15 mg. 4 times a day, failed to control urinary urgency. The bladder neck was resected transurethrally because of 50 to 80 cc residual urine on several occasions. When the catheter was removed the patient was able to void with a better stream. The urinary incontinence did not improve. Six months later the patient had vesicoureteral reflux (fig. 3, A) associated with bouts of chills and fever. Catheter drainage and treatment with antibiotics failed to halt reflux. Urinary diversion to an ileal conduit was performed and the postoperative course was uneventful. The patient has been free of infection and the hydronephrosis has subsided (fig. 3, B). Case 3. V. F., A-21497, a 40-year-old white
man, had had multiple sclerosis for 6 years and
552
SAMELLAS AND RUBIN
urinary frequency day and night for the past 3 years. The voiding volume ranged between 15 and 60 cc and involuntary loss of urine was a constant complaint. Excretory urography disclosed moderate left hydronephrosis and hydroureter with blunting of the calyces (fig. 4, A). Both ureters were seen cut off at the bladder level. The bladder appeared markedly trabeculated with diminished capacity. A suprapubic cystostomy was performed elsewhere because of bleeding from severe hemorrhagic cystitis. Anticholinergic drugs and antibiotics were ineffective. The patient also had bouts of flank pain associated with chills and fever. Urinary diversion to an ileal conduit was performed uneventfully. The infection, hydronephrosis, and blunting of calyces have subsided (fig. 4, B). There is an erroneous conception that patients with multiple sclerosis are poor surgical risks. All patients withstood surgery and anesthesia with-
out incident and behaved similar to any other patient. Urinary diversion should be performed as soon as progressive upper urinary tract changes develop and before irreversible da1nage occurs in the kidneys. Our results are encouraging. By preserving renal function, one of the main causes of death is eliminated and life becomes more comfortable for the patient. SUMMARY
The urinary tract was involved in 55 per cent of the cases in a study of 165 patients with multiple sclerosis. Urologic disease was attributed as the main cause of death in half of the cases. Urinary diversion to an ileal conduit is the procedure of choice when progressive upper urinary tract changes develop. Infection was eliminated, the upper urinary tracts were restored to normal and renal function was preserved.