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The neurological examination
WILLIAM GERALD
E. BRADLEY, W. TIMM,
F. BRANTLEY
M.D.
M.D.
SCOTT,
M.D.
From the Department of Neurology and Neurosurgery, University of Minnesota, Minneapolis, and Division of Urology, Department of Surgery, Baylor College of Medicine, Houston, Texas
ABSTRACT
- The neurologic
test system
fw
urinary incontinence
test system is particularly important in the latter group. The following neurologic findings are important in establishing the presence of neurologic deficit and in the evaluation of test results.
The diagnosis of neurologic dysfunction of the urinary bladder and reproductive system can be a perplexing clinical problem. During the past decade considerable effort has been made to delineate laboratory methods of validating this diagnosis. The need for improved diagnostic techniques has been increased by the recent introduction of prosthetic devices for the treatment of urinary incontinence and male impotence.‘,’ The performance and evaluation of these test systems has emphasized the need for physicians with combined uro- and neurologic training. The neurourologic examination for the diagnosis of urinary incontinence has been developed in great detail and will be explored in depth in this article.
1. Pyramidal tract interruption which is manifested by (a) extensor plantar responses, the Babinski reflex, and (b) inability to volitionally contract the anal sphincter on command in a patient with normal anal sphincter tone. 2. Evidence of basal ganglia disease: principal signs are rigidity, akinesia, and tremor of the extremities. 3. Cerebellar dysfunction: dysmetria and incoordination of the extremities. 4. Spinal cord disease: Supra-nuclear involvement above the level of the sacral spinal cord is manifested by loss of volitional control of sphincter contraction. Infranuclear loss is evident by loss of the bulbocavernosus reflex, loss of tone in the anal sphincter, and hypoesthesia and hypalgesia in sacral dermatomes. 5. Peripheral neuropathy is manifested by impaired-to-absent deep tendon reflexes, distal and hypoesthesia and muscle weakness, hypalgesia in peripheral nerve distribution. From initial history and examination, the physician can form an opinion on the nature ofthe primary neurologic disease. Urinary symptoms and subsequent results of bladder function tests can then be assessed in perspective. The neurologic diseases most frequently associated with bladder dysfunction are:
Neurourologic Test System for Urinary Incontinence History
cd
neurologic
examination
history and neurologic examination are particularly important in determining the presence or absence of overt neurologic disease. hgany examinations of bladder function including cystometry and electromyography have been performed by us in which the evaluation of test results depended on the initial determination of a primary neurologic diagnosis. Several groupings of patients can be made as a result of the initial history and examination. Patients in the first group have a diangosis of primary neurologic disease and urinary bladder dysfunction as a consequence of disease. In the second group of patients primary neurologic disease is not evident, but neuromuscular disease of the lower urinary tract is suspected. The diagnostic The
C’HOLo<:Y
f
DECEMBER
1974
/ VOLC’ME
IV. NUMBER
is described.
1. Cerebrovascular occlusive disease 2. Parkinson’s disease 3. Traumatic spinal cord injury
6
767
4. Myelodysplasia 5. Multiple sclerosis 6. Diabetes mellitus
with peripheral neuropathy 7. Brain and spinal cord tumors
8. 9. 10. 11.
associated
Mental retardation and dementia Adverse response to drug administration Nocturnal enuresis Psychophysiologic reactions
From the initial neurologic examination and assessment of whether or not the patient has neurologic disease and deficit, the bladder function test system may then be implemented. The principal value of this testing is to determine if end organ neurologic disease is present without overt disease of the nervous system. Cystomet?-y Cystometry may be performed by distending the bladder either with fluid or carbon dioxide.3 The cystometrogram may be performed with the patient either in the supine or upright position. When cystometry is used in conjunction with urinary flow measurements, utilization of fluid is mandatory. The principal determination to be made from a cystometrogram is the presence or absence of a detrusor reflex and the patient’s ability to volitionally suppress the reflex. When the patient is unable to voluntarily suppress the reflex, interruption of the cortico- or spino-regulatory tracts is suggested. This finding is known as detrusor hyperreflexia or “uninhibited” urinary bladder. Sensation in bladder also may be measured during cystometry but is unreliable due to the sensory impulses derived from structures contiguous to the bladder.
particular value in localizing the nature of urethral resistance and in evaluating function of the artificial urinary sphincter. Sphincterometry consists of measuring the critical opening pressure of the urethra from external urinary meatus to bladder neck. ELECTROMYOGRAPHY. 6 Recordings of electromyographic activity can be made either from the periurethral striated muscle or anal sphincter. The latter recordings are made with the urethra occluded, utilizing gas cystometry. From these studies we can observe reaction patterns of the periurethral striated muscle and pelvic floor musculature to bladder distention and detrusor reflex contraction. These patterns are best recorded by utilization of electronic integrators for registration of electromyographic activity. Patterns that may be observed are: (1) Healthy volunteers demonstrated increased electromyographic activity with increasing bladder distention; with the occurrence of detrusor reflex contraction, the volunteer can contract or relax the periurethral striated muscle volitionally. (2) The patient cannot voluntarily contract or relax the periurethral striated muscle with bladder distention and during a detrusor reflex. The periurethral striated muscle may respond either with increased contraction to bladder distention, referred to as detrusor-sphincter dyssynergia, or may relax in an uncontrollable manner, referred to as uninhibited urinary sphincter relaxation. 7 Needle electrode examination of pelvic floor musculature utilizes the electromyographic signs of acute and chronic denervation of the striated musculature to determine if interruption of the nerve supply has occurred. These signs include the appearance of fibrillation potentials in acutely denervated muscle and polyphasic reinnervation potentials in chronic denervation.
Micturition studies Micturition studies may he performed to determine ifurinary outflow tract obstruction is present as a sequel to neuromuscular dysfunction4 These consist of simultaneous measurement of intravesical pressure, urinary flow rates, and sphincter electromyography. Correlation of obstruction with sphincter electromyographic activity will decide ifthis obstruction is secondary to sphincter hyperactivity. Urethral fwction
tests
Urethral pressure pro&s. Urethral pressure profile entails measuring the critical opening pressure of the urethra.5 This measurement is of
768
Electrophysiologic
studies of bladder innervation
Electromyelography is an electrophysiologic technique for measurement of the anatomic integrity of the segmental innervation of the detrusor muscle and periurethral striated muscle as well as the cortico-regulatory tracts.s The technique consists of electrical stimulation of bladder and urethral sensory endings with subsequent recording of relayed impulses in the periurethral striated muscle. Electroencephalography and cortical evoked potentials are used for evaluation of the anatomic integrity of the neural pathways from the bladder and periurethral striated muscle to the cerebral
UROLOGY
/
DECEMBER
1974
I VOLUME IV, NUMBER 6
Impulses are generated in sensory nerve endings in the end organ by catheter electrode stimulation and responses recorded in cranial scalp electrodes.
Summary
cortex.
Phnrrnncologic
The neurourologic test system for urinary incontinence has been described. Follow-up articles will discuss individual aspects of the test schedule. However, we wish to emphasize that evaluation of data from these tests is best made by persons with combined training in neurology and urology. Minneapolis, Minnesota 55455 (DR. BRADLEY)
studies
Increasing attention is being directed to the utilization of pharmacologic agents in the diagnosis and management of neurologic bladder dysfunction. When these agents are administered parenterally at the time of performance of the previously described tests, an estimate of their therapeutic efficacy may be made. Diagnostically, denervation supersensitivity has been utilized to determine if end organ .denervation was present.g A cystometrogram performed prior to and after administration of bethanecol will show increased displacement of the tonus limb if denervation was present. Prognosis of the therapeutic efficacy of cholinergic, anti-cholinergic and adrenergic agents may be made by administration .during cystometry, sphincter electromyography, and measurement of urethral pressure profiles. Detrusur
und sphincter
muscle
References F. B., BRADLEY, W. E., and TIMM, G. W.: 1. Scar-r, Managementoferectile impotence: use ofanimplantable, inflatable prosthesis, Urology 2: 80 (1973). 2. IDEM: Treatment of urinary incontinence by an implantable prosthetic urinary sphincter, J. Urol. 112: 75 (1974). 3. BRADLEY, W. E., TIMM, G. W., and SCOTT, F. B.: Neurourological selection of patients for restoration of micturition reflex, Symposia Specialists, Miami, Florida, 1973. 4. SCOTT, F. B., QUESADA, E. M., and CARDUS, D.: Studies on the dynamics of micturition: observations on healthy men, J. Urol. 92: 455 (1964). 5. GLEASON, D. M., REILLY, R. J., BOTTACINI, M., and PIERCE, M. J.: The urethral continence zone and its relationship to stress incontinence, ibid. 112: 81(1974). 6. BRADLEY, W. E., SCOTT, F. B., and TIMM, G. W.: Sphincter electromyography, Urol. Clin. North Am. 1: 69 (1974). BRADLEY, W. E., LOGOTHETIS, J. L., and TIMM, G. W. : Cystometric and sphincter abnormalities in multiple sclerosis, Neurology 23: 1131 (1973). BRADLEY, W. E.: Urethral electromyelography, J. Urol. 108: 563 (1972). LAPIDES, J., FRIEND, C., AJEMIAN, E., and REUS, W. A new test for neurogrenic bladder, ibid. 88: 245 &62).
biopsy
The technique ofbiopsy of detrusor and sphincter muscle has not been utilized in an extensive manner for the diagnosis of end organ disease. Individnal case reports of the histology of the detrusor muscle in different diseases attests to its usefulness. Biochemical determination of collagen and muscle composition of the detrusor muscle still await clinical application.
UROLOGY
/
IIECEMBER
1974
/’ VOLUME
I\‘. NUMBER
6
769
E. BRADLEY, W. TIMM,
F. BRANTLEY
M.D.
M.D.
SCOTT,
M.D.
From the Department of Neurology and Neurosurgery, University of Minnesota, Minneapolis, and Division of Urology, Department of Surgery, Baylor College of Medicine, Houston, Texas
ABSTRACT
- The neurologic
test system
fw
urinary incontinence
test system is particularly important in the latter group. The following neurologic findings are important in establishing the presence of neurologic deficit and in the evaluation of test results.
The diagnosis of neurologic dysfunction of the urinary bladder and reproductive system can be a perplexing clinical problem. During the past decade considerable effort has been made to delineate laboratory methods of validating this diagnosis. The need for improved diagnostic techniques has been increased by the recent introduction of prosthetic devices for the treatment of urinary incontinence and male impotence.‘,’ The performance and evaluation of these test systems has emphasized the need for physicians with combined uro- and neurologic training. The neurourologic examination for the diagnosis of urinary incontinence has been developed in great detail and will be explored in depth in this article.
1. Pyramidal tract interruption which is manifested by (a) extensor plantar responses, the Babinski reflex, and (b) inability to volitionally contract the anal sphincter on command in a patient with normal anal sphincter tone. 2. Evidence of basal ganglia disease: principal signs are rigidity, akinesia, and tremor of the extremities. 3. Cerebellar dysfunction: dysmetria and incoordination of the extremities. 4. Spinal cord disease: Supra-nuclear involvement above the level of the sacral spinal cord is manifested by loss of volitional control of sphincter contraction. Infranuclear loss is evident by loss of the bulbocavernosus reflex, loss of tone in the anal sphincter, and hypoesthesia and hypalgesia in sacral dermatomes. 5. Peripheral neuropathy is manifested by impaired-to-absent deep tendon reflexes, distal and hypoesthesia and muscle weakness, hypalgesia in peripheral nerve distribution. From initial history and examination, the physician can form an opinion on the nature ofthe primary neurologic disease. Urinary symptoms and subsequent results of bladder function tests can then be assessed in perspective. The neurologic diseases most frequently associated with bladder dysfunction are:
Neurourologic Test System for Urinary Incontinence History
cd
neurologic
examination
history and neurologic examination are particularly important in determining the presence or absence of overt neurologic disease. hgany examinations of bladder function including cystometry and electromyography have been performed by us in which the evaluation of test results depended on the initial determination of a primary neurologic diagnosis. Several groupings of patients can be made as a result of the initial history and examination. Patients in the first group have a diangosis of primary neurologic disease and urinary bladder dysfunction as a consequence of disease. In the second group of patients primary neurologic disease is not evident, but neuromuscular disease of the lower urinary tract is suspected. The diagnostic The
C’HOLo<:Y
f
DECEMBER
1974
/ VOLC’ME
IV. NUMBER
is described.
1. Cerebrovascular occlusive disease 2. Parkinson’s disease 3. Traumatic spinal cord injury
6
767
4. Myelodysplasia 5. Multiple sclerosis 6. Diabetes mellitus
with peripheral neuropathy 7. Brain and spinal cord tumors
8. 9. 10. 11.
associated
Mental retardation and dementia Adverse response to drug administration Nocturnal enuresis Psychophysiologic reactions
From the initial neurologic examination and assessment of whether or not the patient has neurologic disease and deficit, the bladder function test system may then be implemented. The principal value of this testing is to determine if end organ neurologic disease is present without overt disease of the nervous system. Cystomet?-y Cystometry may be performed by distending the bladder either with fluid or carbon dioxide.3 The cystometrogram may be performed with the patient either in the supine or upright position. When cystometry is used in conjunction with urinary flow measurements, utilization of fluid is mandatory. The principal determination to be made from a cystometrogram is the presence or absence of a detrusor reflex and the patient’s ability to volitionally suppress the reflex. When the patient is unable to voluntarily suppress the reflex, interruption of the cortico- or spino-regulatory tracts is suggested. This finding is known as detrusor hyperreflexia or “uninhibited” urinary bladder. Sensation in bladder also may be measured during cystometry but is unreliable due to the sensory impulses derived from structures contiguous to the bladder.
particular value in localizing the nature of urethral resistance and in evaluating function of the artificial urinary sphincter. Sphincterometry consists of measuring the critical opening pressure of the urethra from external urinary meatus to bladder neck. ELECTROMYOGRAPHY. 6 Recordings of electromyographic activity can be made either from the periurethral striated muscle or anal sphincter. The latter recordings are made with the urethra occluded, utilizing gas cystometry. From these studies we can observe reaction patterns of the periurethral striated muscle and pelvic floor musculature to bladder distention and detrusor reflex contraction. These patterns are best recorded by utilization of electronic integrators for registration of electromyographic activity. Patterns that may be observed are: (1) Healthy volunteers demonstrated increased electromyographic activity with increasing bladder distention; with the occurrence of detrusor reflex contraction, the volunteer can contract or relax the periurethral striated muscle volitionally. (2) The patient cannot voluntarily contract or relax the periurethral striated muscle with bladder distention and during a detrusor reflex. The periurethral striated muscle may respond either with increased contraction to bladder distention, referred to as detrusor-sphincter dyssynergia, or may relax in an uncontrollable manner, referred to as uninhibited urinary sphincter relaxation. 7 Needle electrode examination of pelvic floor musculature utilizes the electromyographic signs of acute and chronic denervation of the striated musculature to determine if interruption of the nerve supply has occurred. These signs include the appearance of fibrillation potentials in acutely denervated muscle and polyphasic reinnervation potentials in chronic denervation.
Micturition studies Micturition studies may he performed to determine ifurinary outflow tract obstruction is present as a sequel to neuromuscular dysfunction4 These consist of simultaneous measurement of intravesical pressure, urinary flow rates, and sphincter electromyography. Correlation of obstruction with sphincter electromyographic activity will decide ifthis obstruction is secondary to sphincter hyperactivity. Urethral fwction
tests
Urethral pressure pro&s. Urethral pressure profile entails measuring the critical opening pressure of the urethra.5 This measurement is of
768
Electrophysiologic
studies of bladder innervation
Electromyelography is an electrophysiologic technique for measurement of the anatomic integrity of the segmental innervation of the detrusor muscle and periurethral striated muscle as well as the cortico-regulatory tracts.s The technique consists of electrical stimulation of bladder and urethral sensory endings with subsequent recording of relayed impulses in the periurethral striated muscle. Electroencephalography and cortical evoked potentials are used for evaluation of the anatomic integrity of the neural pathways from the bladder and periurethral striated muscle to the cerebral
UROLOGY
/
DECEMBER
1974
I VOLUME IV, NUMBER 6
Impulses are generated in sensory nerve endings in the end organ by catheter electrode stimulation and responses recorded in cranial scalp electrodes.
Summary
cortex.
Phnrrnncologic
The neurourologic test system for urinary incontinence has been described. Follow-up articles will discuss individual aspects of the test schedule. However, we wish to emphasize that evaluation of data from these tests is best made by persons with combined training in neurology and urology. Minneapolis, Minnesota 55455 (DR. BRADLEY)
studies
Increasing attention is being directed to the utilization of pharmacologic agents in the diagnosis and management of neurologic bladder dysfunction. When these agents are administered parenterally at the time of performance of the previously described tests, an estimate of their therapeutic efficacy may be made. Diagnostically, denervation supersensitivity has been utilized to determine if end organ .denervation was present.g A cystometrogram performed prior to and after administration of bethanecol will show increased displacement of the tonus limb if denervation was present. Prognosis of the therapeutic efficacy of cholinergic, anti-cholinergic and adrenergic agents may be made by administration .during cystometry, sphincter electromyography, and measurement of urethral pressure profiles. Detrusur
und sphincter
muscle
References F. B., BRADLEY, W. E., and TIMM, G. W.: 1. Scar-r, Managementoferectile impotence: use ofanimplantable, inflatable prosthesis, Urology 2: 80 (1973). 2. IDEM: Treatment of urinary incontinence by an implantable prosthetic urinary sphincter, J. Urol. 112: 75 (1974). 3. BRADLEY, W. E., TIMM, G. W., and SCOTT, F. B.: Neurourological selection of patients for restoration of micturition reflex, Symposia Specialists, Miami, Florida, 1973. 4. SCOTT, F. B., QUESADA, E. M., and CARDUS, D.: Studies on the dynamics of micturition: observations on healthy men, J. Urol. 92: 455 (1964). 5. GLEASON, D. M., REILLY, R. J., BOTTACINI, M., and PIERCE, M. J.: The urethral continence zone and its relationship to stress incontinence, ibid. 112: 81(1974). 6. BRADLEY, W. E., SCOTT, F. B., and TIMM, G. W.: Sphincter electromyography, Urol. Clin. North Am. 1: 69 (1974). BRADLEY, W. E., LOGOTHETIS, J. L., and TIMM, G. W. : Cystometric and sphincter abnormalities in multiple sclerosis, Neurology 23: 1131 (1973). BRADLEY, W. E.: Urethral electromyelography, J. Urol. 108: 563 (1972). LAPIDES, J., FRIEND, C., AJEMIAN, E., and REUS, W. A new test for neurogrenic bladder, ibid. 88: 245 &62).
biopsy
The technique ofbiopsy of detrusor and sphincter muscle has not been utilized in an extensive manner for the diagnosis of end organ disease. Individnal case reports of the histology of the detrusor muscle in different diseases attests to its usefulness. Biochemical determination of collagen and muscle composition of the detrusor muscle still await clinical application.
UROLOGY
/
IIECEMBER
1974
/’ VOLUME
I\‘. NUMBER
6
769