- Email: [email protected]
Operations for Urinary Control of Neurogenic Bladders1
OPERATIONS FOR URINARY CONTROL OF NEUROGENIC BLADDERS1 REX E. VAN DUZEN
War injuries have brought many perplexing problems to the urologist in the past. In the last 25 years we have gained new knowledge of the physiology and the anatomy of the bladder. Added to this is the fact that with the new drugs, infections of the genito-urinary tract, which formerly killed most cases of neurogenic bladders, can now be combatted. Realizing these facts, we should begin to discuss means of alleviating the sufferings of these unfortunate patients. I will not discuss the problems of the acute injury to the nerve supply of the bladder. I will only discuss the problems presented in a hospital for crippled children, hoping we may gain some knowledge which will be useful later in treating war injuries to the bladder and its nerve supply. The nerve supply of the bladder is chiefly from two sources. The sympathetic nerves reach the bladder chiefly by way of the presacral nerves but some fibres pass by way of the sacral nerves. Stimulation of the sympathetic nerves causes contraction of the trigone muscle. Langworthy and Dees state that stimulation causes relaxation in atonic bladders of the cat. I have never observed like action in the human. The parasympathetic nerves reach the bladder through the sacral nerves and supply the detrusor muscle of the bladder and the involuntary muscles of the bladder neck. Stimulation of the sacral nerves causes contraction of the bladder wall and the "so-called" internal sphincter of the urethra. Section of the sacral nerves produces relaxation of the bla<:lder and posterior urethra except when the prostate has enlarged and replaced the internal sphincter. In such cases, the section of the nerves may not influence the deep urethra because it may have become a rigid structure. The external or voluntary sphincter receives its nerve supply through the pudic nerves. Section of these nerves produces, in most cases, the true incontinence of the bladder without paralysis of the bladder wall. Lastly we must consider injuries to the brain and upper spinal cord. These usually produce incontinence of the bladder. Neurogenic bladder is often associated with like pathological changes in the rectum, and this immediately precludes the transplantation of the ureters into the rectum. Rose suggested converting the partially incontinent bladder into one totally incontinent. He deliberately made several cuts with the resectoscope through the external urethral sphincter. The urine was then controlled by the incontinence clamp. In selected cases, this is an excellent solution of a difficult situation. But it is not applicable to the female patient. I have found children and many men unable to wear the clamp. In some cases, the shaft of the penis is too short to permit sufficient pressure or the clamp is continually slipping off. Pressure sores have been very common. I will use the classification given by McLellan in The N eurogenic Bladder: (1) The uninhibited neurogenic bladder; (2) reflex neurogenic bladder; (3) the autonomous neurogenic bladder; (4) the atonic neurogenic bladder. 1
Read at annual meeting, American Urological Association, St. Louis, Mo., June 20,
1944. 565
566
REX E. VAN DUZEN GROUP
1
The enuretic child is the best example of the uninhibited neurogenic bladder. Its counterpart is the over-inhibited bladder of dementia praecox. I have found many cases of enuresis improved by ephedrine. Ephedrine is a sym- pathetic nerve stimulant. Slaughter and myself were unable to demonstrate any inhibitory action in the dog's bladder which had been activated by morphine. (fig. 1) Ephedrine also acts upon the brain and I suspect it increases the inhibition that these cases lack. A few cases have been unable to continue because of extreme nervousness. Recently, I have used methyl testesterone with good results. But we have seen a few cases which did not respond to any medical treatment. I have resected the presacral nerve with excellent results in these cases. Case 1. Miss M., aged 15, was referred to me by the Child Guidance Clinic because of enuresis. This child has had prolonged psychoanalytical studies with no improvement. She was becoming an introvert because of her malady. Physical and cystoscopic examinations,were negative. In July 1941 a presacral resection was performed. The results were immediate and complete. She entered college in September 1941. She carried the usual scholastic work and acted as secretary to the college president. She married in 1943 and I saw her about January 1944. She was then several months pregnant and reported there had been no return of eneuresis. I pointed out in a recent article that the conception that presacral nerve resection produces a delay and impediment to urination, is contrary to the writings of Learmonth, Langworthy, Kuntz, and others. After many observations, I am able to state that all cases will give the history that there is a delay and impediment tci urination after neurectomy, if questioned carefully. GROUP
2
The treatment of the remaining types of neurogenic bladder depends on whether the micturition is precipitate or involuntary. If it is precipitate trasentin may be useful. Case 2. Miss H ., aged 9, was seen in the Scottish Rite Hospital in July 1943 for incontinence of urine. She had had transacral fusion in April 1943. She was completely incontinent. There was saddle anesthesia. The patient was in a plaster cast and muscle action could not be tested. Cystometric study showed a filling impulse at 50 cc, desire to void at 350 cc and voiding at 400 cc. Intravesical pressure was 14 at 50, 22 at 350, and 28 at voiding. There was no residual urine. Patient was given 2 tablets of trasentin 3 times a day. She was seen in August 1943. She had complete control of urine which had continued after stopping medication. It has been our practice, in all cases of incontinence, to attempt to substitute a voluntary control for the lost sphincteric action. Lowsley's suggestion that ribbon gut be passed around the urethra has been unsuccessful in our hands because it produced a fibrous ~~ricture which could not b_e ~OlJ!_l_!.3:r~ relaxed.
~~~:rL._. ·---· ~ - · ., ..
_ _ c., ··
~,-~,. . .,r,,;e~
·1=~1.j t~ -
:'"".las..>&
URINARY CONTROL OF NEUROGENIC DLADDEHS
567
In 1926, Deming reported the use of the gracilis muscle transplant for the treatment of incontinence due to epispadias (fig. 2). Looney and myself modified Deming's operation by tunneling beneath the bulbocavernosus muscle rather
Frn. 1. Action of ephedrine sulphate on bladder muscle
than cutting across it (figs. 3 and 4). Player and Callender reported a similar modification in the male. This has been the operation we have preferred. But a successful result depends on the patient walking with the leg slightly adducted.
568
REX E. VAN DUZEN
Fm. 2. Deming's operation of transplantation of gracilis muscle encircling urethra
Fm. 3. Muscle brought through tunnel and sutured to opposite rami
When the leg is abducted, the urethra is opened and urine escapes. In sleep, some cases have used a "hobble like" bandage at the knees to prevent abduction. Some cases have a flaccid knee joint and find it impossible to keep the leg adducted. Others have ulcers about the perineum or thighs from constant soiling,
-----------------~---"--'----__c_--~-~---~---
569
URINARY CONTROL OF NEUROGENIC BLADDERS
Fm. 4. Operation: Transplantation of gracilis muscle. Looney modification
and
Van Duzen
Fm. 5. Operation devised by Price
pressure from braces or trophic ulcers. These cases are unsuitable for gracilis muscle transplant. In these cases, we have used an operation devised by Price (fig. 5). He attempted to gain sphincteric action by passing a sling of fascia
510
REX E. VAN DUZEN
lata under the deep urethra through a suprapubic incision and sutured the ends to the rectus fascia. Contraction of the rectus muscle exerted pressure on the posterior surface of the urethra sufficient to close it. Aldridge has suggested the use of fascia! strips derived from the rectus fascia which are drawn down and sutured beneath the urethra through a vaginal incision. I have used kangaroo tendon and ribbon gut, but prefer the former. I have found it difficult to pass the suture beneath the urethra from a suprapubic incision, and in boys, have used Aldridge's suggestion of drawing the suture down through a perineal incision and passing it back upward on the opposite side of the urethra, forming a V shaped sling. The ends are then drawn taut and sutured to rectus fascia near the umbilicus. In girls, because of the infection about vagina and ulcerated perineum, I have preferred to use the suprapubic incision only and guided the needle with the finger in the vagina. If the ends are not sutured fairly high on the rectus fascia, or if the lumbar spine is not rigid, the patient is unable to exert sufficient pressure on the urethra to close it. Case 3. Miss K., age 11, gave a history of incontinence of urine since birth. The mother stated that the child had had a meningocele operation at 11 months of age and had never developed any urinary control. On June 10, 1940, I transplanted the gracilis muscle beneath the urethra. The results were only partially successful. On August 17, 1940, I performed the presacral neurectomy and at the same time plicated the rectal sphincter with ribbon gut suture, as described by Lowsley. I have never obtained so satisfactory a result from the gracilis muscle transplant as in this case. COMMENT
I performed the presacral neurectomy hoping that it might delay the starting of urination until she could by voluntary action exert pressure on the urethra. I then tried presacral nerve resection of similar cases without a plastic operation on the urethra. I saw little or no benefit from this procedure alone. In 1943 I called back to the hospital 2 cases of neurogenic bladder on whom I had previously performed a gracilis muscle transplant, with mediocre results. I performed a presacral neurectomy on each case with marked improvement but not complete control. It is my present belief that a case with loss of detrusor muscle action and with a functionating trigon muscle, is constantly opening theinternal sphincter and allowing .escape of urine. If one paralyzes the trigone by presacral neurectomy, this does not occur. If one has a voluntary control such as after gracilis muscle transplant, he can then open the urethra at will by abducting the thighs. A recent observation has confused the situation, however. Case 4- H.B., aged 8, was seen in November 1942 for flaccid paralysis below the knees and incontinence of urine. The patient had had spinal bifida operation when she was 1 year old, and had never developed urinary control. A Gracilis muscle transplant about the urethra was performed in November 1942. Urinary control was only partial. Presacral neurectomy was performed in May 1943 with marked improvement. In April 1944, patient was given ephedrine sulphate, ¾grain twice daily, with complete control of urine. In May 1944 ephedrine
URINARY CONTROL OF NEUROGENIC BLADDERS
571
sulphate was stopped and methyl testesterone given. There was immediate loss of urinary control. After 1 week's treatment, ephedrine sulphate was given again with slow return of urinary control. Dr. Slaughter, professor of pharmacology at Southwestern Medical Foundation, believes benzedrine sulphate and ephedrine have both a sympathomimetic and a central action. He has found that they produce an apathy which dulls the perception and the normal stimuli fails to produce the desire to urinate. This results in the bladder increasing its capacity, not from inhibiting the detrusor muscle but from lessening the central stimuli. In the above case, we had previously cut the sympathetic nerves and most of the parasympathe't ic nerves were partially destroyed by the spinal bifida or by the operation for its repair. We feel in the past, the role of the central stimuli have not been sufficiently stressed. The results in these cases depend on the after treatment. We have found it very important to teach the patient how to close the urethra, by either adducting the thigh or contracting the abdominal wall, depending on the method used. They should be able to feel the pull on the urethra. We have also insisted on the use of electrical stimulation to the transplanted muscle. Some type of an induction coil is used where electrical current is available. We have found a hand-cranked generator taken from a telephone set satisfactory if electrical current is not available. CONCLUSIONS
The uninhibited neurogenic bladder may be relieved by ephedrine sulphate or methyl testesterone. A few cases may require presacral neurectomy. Trasentin may improve the over-inhibited neurogenic bladder seen in dementia praecox. It also is useful in cases due to central irritation. The gracilis muscle transplant combined with presacral neurectomy is a very useful substitute for a paralyzed or incompetent external urethral sphincter. The V shaped sling passed beneath the urethra and sutured to fascia of rectus muscle has been useful in selected cases. Resection of the presacral nerve has improved the results.
721 Medical Arts Bldg., Dallas, Texas REFERENCES ALDRIDGE: Transplantation of fascia for relief of urinary stress incontinence . Am. J . Obst. & Gynec., 44: 398--411, 1942. DEMING: Transplantation of gracilis muscle for incontinence of urine. J . A. M. A., 86: 822, 1926. LowsLEY AND HUNT: A new operation for relief of incontinence of urine and feces . Pre.liminary report. J. Urol., 41: 252-263, 1939. McLELLAN: The Neurogenic Bladder. Springfield, Ill.: Charles C. Thomas, 1939. PRICE: Plastic operation for incontinence of urine and of feces. Arch. Surg., 26: 10431053, 1933. PLAYER AND CALLENDER: A method for cure or urinary incontinence in the male . J. A. M.A., 88: 989- 991, 1927. RozE AND SHEFTS: Tabetic bladder. South. Med. J., 32: 546- 549, 1939. SLAUGHTER AND VAN Du ZEN: The pharmalogic action of drugs on isolated ureter. South . Med . J., 36: 541-547, 1942. VAN DuzEN AND LooNEY: A resume of 6 years of cystoceles. Urol. and Cutan. Rev., 36: 603-605, 1932. - ~~~~ftt~lll...,i\Lil!.in.,,,..,.......""""' .,.. ti ·= kl:ll;....,_.·""' ~-~-• .
War injuries have brought many perplexing problems to the urologist in the past. In the last 25 years we have gained new knowledge of the physiology and the anatomy of the bladder. Added to this is the fact that with the new drugs, infections of the genito-urinary tract, which formerly killed most cases of neurogenic bladders, can now be combatted. Realizing these facts, we should begin to discuss means of alleviating the sufferings of these unfortunate patients. I will not discuss the problems of the acute injury to the nerve supply of the bladder. I will only discuss the problems presented in a hospital for crippled children, hoping we may gain some knowledge which will be useful later in treating war injuries to the bladder and its nerve supply. The nerve supply of the bladder is chiefly from two sources. The sympathetic nerves reach the bladder chiefly by way of the presacral nerves but some fibres pass by way of the sacral nerves. Stimulation of the sympathetic nerves causes contraction of the trigone muscle. Langworthy and Dees state that stimulation causes relaxation in atonic bladders of the cat. I have never observed like action in the human. The parasympathetic nerves reach the bladder through the sacral nerves and supply the detrusor muscle of the bladder and the involuntary muscles of the bladder neck. Stimulation of the sacral nerves causes contraction of the bladder wall and the "so-called" internal sphincter of the urethra. Section of the sacral nerves produces relaxation of the bla<:lder and posterior urethra except when the prostate has enlarged and replaced the internal sphincter. In such cases, the section of the nerves may not influence the deep urethra because it may have become a rigid structure. The external or voluntary sphincter receives its nerve supply through the pudic nerves. Section of these nerves produces, in most cases, the true incontinence of the bladder without paralysis of the bladder wall. Lastly we must consider injuries to the brain and upper spinal cord. These usually produce incontinence of the bladder. Neurogenic bladder is often associated with like pathological changes in the rectum, and this immediately precludes the transplantation of the ureters into the rectum. Rose suggested converting the partially incontinent bladder into one totally incontinent. He deliberately made several cuts with the resectoscope through the external urethral sphincter. The urine was then controlled by the incontinence clamp. In selected cases, this is an excellent solution of a difficult situation. But it is not applicable to the female patient. I have found children and many men unable to wear the clamp. In some cases, the shaft of the penis is too short to permit sufficient pressure or the clamp is continually slipping off. Pressure sores have been very common. I will use the classification given by McLellan in The N eurogenic Bladder: (1) The uninhibited neurogenic bladder; (2) reflex neurogenic bladder; (3) the autonomous neurogenic bladder; (4) the atonic neurogenic bladder. 1
Read at annual meeting, American Urological Association, St. Louis, Mo., June 20,
1944. 565
566
REX E. VAN DUZEN GROUP
1
The enuretic child is the best example of the uninhibited neurogenic bladder. Its counterpart is the over-inhibited bladder of dementia praecox. I have found many cases of enuresis improved by ephedrine. Ephedrine is a sym- pathetic nerve stimulant. Slaughter and myself were unable to demonstrate any inhibitory action in the dog's bladder which had been activated by morphine. (fig. 1) Ephedrine also acts upon the brain and I suspect it increases the inhibition that these cases lack. A few cases have been unable to continue because of extreme nervousness. Recently, I have used methyl testesterone with good results. But we have seen a few cases which did not respond to any medical treatment. I have resected the presacral nerve with excellent results in these cases. Case 1. Miss M., aged 15, was referred to me by the Child Guidance Clinic because of enuresis. This child has had prolonged psychoanalytical studies with no improvement. She was becoming an introvert because of her malady. Physical and cystoscopic examinations,were negative. In July 1941 a presacral resection was performed. The results were immediate and complete. She entered college in September 1941. She carried the usual scholastic work and acted as secretary to the college president. She married in 1943 and I saw her about January 1944. She was then several months pregnant and reported there had been no return of eneuresis. I pointed out in a recent article that the conception that presacral nerve resection produces a delay and impediment to urination, is contrary to the writings of Learmonth, Langworthy, Kuntz, and others. After many observations, I am able to state that all cases will give the history that there is a delay and impediment tci urination after neurectomy, if questioned carefully. GROUP
2
The treatment of the remaining types of neurogenic bladder depends on whether the micturition is precipitate or involuntary. If it is precipitate trasentin may be useful. Case 2. Miss H ., aged 9, was seen in the Scottish Rite Hospital in July 1943 for incontinence of urine. She had had transacral fusion in April 1943. She was completely incontinent. There was saddle anesthesia. The patient was in a plaster cast and muscle action could not be tested. Cystometric study showed a filling impulse at 50 cc, desire to void at 350 cc and voiding at 400 cc. Intravesical pressure was 14 at 50, 22 at 350, and 28 at voiding. There was no residual urine. Patient was given 2 tablets of trasentin 3 times a day. She was seen in August 1943. She had complete control of urine which had continued after stopping medication. It has been our practice, in all cases of incontinence, to attempt to substitute a voluntary control for the lost sphincteric action. Lowsley's suggestion that ribbon gut be passed around the urethra has been unsuccessful in our hands because it produced a fibrous ~~ricture which could not b_e ~OlJ!_l_!.3:r~ relaxed.
~~~:rL._. ·---· ~ - · ., ..
_ _ c., ··
~,-~,. . .,r,,;e~
·1=~1.j t~ -
:'"".las..>&
URINARY CONTROL OF NEUROGENIC DLADDEHS
567
In 1926, Deming reported the use of the gracilis muscle transplant for the treatment of incontinence due to epispadias (fig. 2). Looney and myself modified Deming's operation by tunneling beneath the bulbocavernosus muscle rather
Frn. 1. Action of ephedrine sulphate on bladder muscle
than cutting across it (figs. 3 and 4). Player and Callender reported a similar modification in the male. This has been the operation we have preferred. But a successful result depends on the patient walking with the leg slightly adducted.
568
REX E. VAN DUZEN
Fm. 2. Deming's operation of transplantation of gracilis muscle encircling urethra
Fm. 3. Muscle brought through tunnel and sutured to opposite rami
When the leg is abducted, the urethra is opened and urine escapes. In sleep, some cases have used a "hobble like" bandage at the knees to prevent abduction. Some cases have a flaccid knee joint and find it impossible to keep the leg adducted. Others have ulcers about the perineum or thighs from constant soiling,
-----------------~---"--'----__c_--~-~---~---
569
URINARY CONTROL OF NEUROGENIC BLADDERS
Fm. 4. Operation: Transplantation of gracilis muscle. Looney modification
and
Van Duzen
Fm. 5. Operation devised by Price
pressure from braces or trophic ulcers. These cases are unsuitable for gracilis muscle transplant. In these cases, we have used an operation devised by Price (fig. 5). He attempted to gain sphincteric action by passing a sling of fascia
510
REX E. VAN DUZEN
lata under the deep urethra through a suprapubic incision and sutured the ends to the rectus fascia. Contraction of the rectus muscle exerted pressure on the posterior surface of the urethra sufficient to close it. Aldridge has suggested the use of fascia! strips derived from the rectus fascia which are drawn down and sutured beneath the urethra through a vaginal incision. I have used kangaroo tendon and ribbon gut, but prefer the former. I have found it difficult to pass the suture beneath the urethra from a suprapubic incision, and in boys, have used Aldridge's suggestion of drawing the suture down through a perineal incision and passing it back upward on the opposite side of the urethra, forming a V shaped sling. The ends are then drawn taut and sutured to rectus fascia near the umbilicus. In girls, because of the infection about vagina and ulcerated perineum, I have preferred to use the suprapubic incision only and guided the needle with the finger in the vagina. If the ends are not sutured fairly high on the rectus fascia, or if the lumbar spine is not rigid, the patient is unable to exert sufficient pressure on the urethra to close it. Case 3. Miss K., age 11, gave a history of incontinence of urine since birth. The mother stated that the child had had a meningocele operation at 11 months of age and had never developed any urinary control. On June 10, 1940, I transplanted the gracilis muscle beneath the urethra. The results were only partially successful. On August 17, 1940, I performed the presacral neurectomy and at the same time plicated the rectal sphincter with ribbon gut suture, as described by Lowsley. I have never obtained so satisfactory a result from the gracilis muscle transplant as in this case. COMMENT
I performed the presacral neurectomy hoping that it might delay the starting of urination until she could by voluntary action exert pressure on the urethra. I then tried presacral nerve resection of similar cases without a plastic operation on the urethra. I saw little or no benefit from this procedure alone. In 1943 I called back to the hospital 2 cases of neurogenic bladder on whom I had previously performed a gracilis muscle transplant, with mediocre results. I performed a presacral neurectomy on each case with marked improvement but not complete control. It is my present belief that a case with loss of detrusor muscle action and with a functionating trigon muscle, is constantly opening theinternal sphincter and allowing .escape of urine. If one paralyzes the trigone by presacral neurectomy, this does not occur. If one has a voluntary control such as after gracilis muscle transplant, he can then open the urethra at will by abducting the thighs. A recent observation has confused the situation, however. Case 4- H.B., aged 8, was seen in November 1942 for flaccid paralysis below the knees and incontinence of urine. The patient had had spinal bifida operation when she was 1 year old, and had never developed urinary control. A Gracilis muscle transplant about the urethra was performed in November 1942. Urinary control was only partial. Presacral neurectomy was performed in May 1943 with marked improvement. In April 1944, patient was given ephedrine sulphate, ¾grain twice daily, with complete control of urine. In May 1944 ephedrine
URINARY CONTROL OF NEUROGENIC BLADDERS
571
sulphate was stopped and methyl testesterone given. There was immediate loss of urinary control. After 1 week's treatment, ephedrine sulphate was given again with slow return of urinary control. Dr. Slaughter, professor of pharmacology at Southwestern Medical Foundation, believes benzedrine sulphate and ephedrine have both a sympathomimetic and a central action. He has found that they produce an apathy which dulls the perception and the normal stimuli fails to produce the desire to urinate. This results in the bladder increasing its capacity, not from inhibiting the detrusor muscle but from lessening the central stimuli. In the above case, we had previously cut the sympathetic nerves and most of the parasympathe't ic nerves were partially destroyed by the spinal bifida or by the operation for its repair. We feel in the past, the role of the central stimuli have not been sufficiently stressed. The results in these cases depend on the after treatment. We have found it very important to teach the patient how to close the urethra, by either adducting the thigh or contracting the abdominal wall, depending on the method used. They should be able to feel the pull on the urethra. We have also insisted on the use of electrical stimulation to the transplanted muscle. Some type of an induction coil is used where electrical current is available. We have found a hand-cranked generator taken from a telephone set satisfactory if electrical current is not available. CONCLUSIONS
The uninhibited neurogenic bladder may be relieved by ephedrine sulphate or methyl testesterone. A few cases may require presacral neurectomy. Trasentin may improve the over-inhibited neurogenic bladder seen in dementia praecox. It also is useful in cases due to central irritation. The gracilis muscle transplant combined with presacral neurectomy is a very useful substitute for a paralyzed or incompetent external urethral sphincter. The V shaped sling passed beneath the urethra and sutured to fascia of rectus muscle has been useful in selected cases. Resection of the presacral nerve has improved the results.
721 Medical Arts Bldg., Dallas, Texas REFERENCES ALDRIDGE: Transplantation of fascia for relief of urinary stress incontinence . Am. J . Obst. & Gynec., 44: 398--411, 1942. DEMING: Transplantation of gracilis muscle for incontinence of urine. J . A. M. A., 86: 822, 1926. LowsLEY AND HUNT: A new operation for relief of incontinence of urine and feces . Pre.liminary report. J. Urol., 41: 252-263, 1939. McLELLAN: The Neurogenic Bladder. Springfield, Ill.: Charles C. Thomas, 1939. PRICE: Plastic operation for incontinence of urine and of feces. Arch. Surg., 26: 10431053, 1933. PLAYER AND CALLENDER: A method for cure or urinary incontinence in the male . J. A. M.A., 88: 989- 991, 1927. RozE AND SHEFTS: Tabetic bladder. South. Med. J., 32: 546- 549, 1939. SLAUGHTER AND VAN Du ZEN: The pharmalogic action of drugs on isolated ureter. South . Med . J., 36: 541-547, 1942. VAN DuzEN AND LooNEY: A resume of 6 years of cystoceles. Urol. and Cutan. Rev., 36: 603-605, 1932. - ~~~~ftt~lll...,i\Lil!.in.,,,..,.......""""' .,.. ti ·= kl:ll;....,_.·""' ~-~-• .