Urinary Dysfunction in Transverse Myelitis

0022-534 7/90/1441-0i.03$02.00/0 Vol. 144, July Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Urological Neurology and Urodynamics URINARY DYSFUNCTION IN TRANSVERSE MYELITIS YITZHAK BERGER, JERRY G. ::BbAIVAS AND LESLIE OLIVER From the Division of Urology, University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey, and Department of Urology, Columbia-Presbyterian Medical Center, New York, New York Center, New York, New York

ABSTRACT

Six men and 2 women with a history of transverse myelitis and persistent lower urinary tract symptoms underwent neurourological evaluation. Of the patients, 4 were neurologically intact, while the remainder had residual neurological deficits. Urodynamic studies revealed detrusor-external sphincter dyssynergia in 6 patients. Two patients had detrusor hyperreflexia, of whom 1 also had an incompetent sphincter. Erectile or ejaculatory dysfunction was reported by 3 men. We conclude that prolonged bladder and sexual dysfunction, caused by spinal cord inflammatory insult, may persist despite a systemic neurological recovery. Therefore, bladder management guided by initial and followup urodynamics is recommended. (J. Ural., 144: 103-105, 1990) Transverse myelitis is an uncommon inflammatory process, usually of viral etiology, that involves the entire thickness of the spinal cord and causes various neurological manifestations.'· 2 Bladder dysfunction is common but there is a paucity of prior reports of this condition in the medical literature. We report our experience with 8 patients who had persistent bladder symptoms after an episode of transverse myelitis" MATERIALS AND METHODS

Eight consecutive patients with a prior diagnosis of transverse myelitis were evaluated (table 1). The neurological diagnosis was based on the clinical presentation (initial paraplegia, paresis or radicular pain preceded commonly by a flu-like disease) and elimination of other etiologies, such as traumatic, obstructing, infiltrating or space-occupying processes in the spinal cord. In 7 patients investigations, such as a spinal tap, myelogram or nuclear magnetic resonance studies of the spine, were performed to rule out such pathological conditions. In l woman, a physician, the only available data record was a history of an acute but temporary paraplegia that occurred 12 years ago while attending medical school, associated with onset of urinary symptoms, and the patient was diagnosed to have had transverse myelitis. None of the patients had subsequent neurological signs or symptoms suggesting multiple sclerosis. The urological assessment consisted of history and a physical examination, concentrating specifically on the perianal sensation, anal tone and control, and eliciting the bulbocavernosus reflex. In addition, urinalysis and excretory urography (IVP) were obtained. Subsequently, the patients underwent a urodynamic evaluation including simultaneous video-pressure-flow electromyographic studies as previously described. 3 A lOF trilumen urodynamic catheter was inserted transurethrally into the bladder. Meglumine diatrizoate ( 14 %) at room temperature was instilled through 1 lumen at a rate consistent with medium filled cystometry. One lumen was used to measure intravesical pressure. A rectal catheter, held in the ampulla by an inflated balloon, was used to measure the intra-abdominal pressure. The detrusor pressure was calculated electronically. Filling pressures were considered normal if they were less than 20 cm. water at bladder capacity. An involuntary detrusor contraction was deAccepted for publication January 24, 1990.

fined as a sudden increase in detrusor pressure that was not volitional. Determination of involuntary versus voluntary bladder contractions and electromyographic activity was obtained by maintaining active contact with the patient throughout the entire urodynamic study. Volumes at which involuntary contractions occurred were noted as well as the awareness by the patient of these contractions, and the ability to stop the stream and/or to suppress the detrusor contraction. Detrusor-external sphincter dyssynergia was defined as persistent and involuntary electromyographic activity during bladder contraction. 4 Urinary flow rate and pressure-flow were studied whenever possible. The pressure-flow study was performed by having the patient void around a lOF catheter. A uroflow rate of 12 m. per second or less that occurred during a detrusor contraction of 45 cm. water or more was considered to indicate bladder outlet obstruction. Five patients underwent full fluoroscopic/urodynamic studies. One woman requested a study without electromyographic and l woman had no fluoroscopic exposure. One man who initially presented with urinary retention and began to void 1 week later opted to be evaluated with uroflow only. RESULTS

Patients. Six men and 2 women 22 to 51 years old were evaluated (table 1). Each patient suffered an episode of transverse myelitis ranging from 3 weeks to 13 years before the initial urodynamic study. Initially, all patients had paraplegia that resolved in 7 within l week to 3 months after onset. Two patients also had temporary coma from which they recovered within 1 week. Urinary symptoms. Symptoms began simultaneously with or shortly after the neurological insult. All patients had acute urinary retention and initially were treated by an indwelling catheter (6) or intermittent catheterization (2). Within l to 6 weeks 3 patients began to void: 2 had urinary frequency, urgency and urge incontinence and 1 complained of a decreased urinary stream. The remaining patients still are managed with intermittent self-catheterization. In addition, l man complained of stress urinary incontinence. In 1 patient a bladder stone was found and removed before the urodynamic study. Two men complained of erectile impotence and 1 was able to

104

BERGER, BLAIVAS AND OLIVER TABLE 1.

Pt. No.-Age-Sex

Onset of Disease

1-38-F 2-37-M 3-37-M

13 yrs. 9mos. 3wks.

4-51-M 5-28-M

2 yrs. 6wks.

6-22-M

1 yr.

7-27-M 8-30-F

2mos. 2 yrs.

Neurological history and examination

Neurological Symptoms None None None None Legs weakness Legs weakness Paraplegia Lt. leg weakness

Urinary Symptoms

Pt. No.

(ml.)

Normal Normal Normal

Normal Normal Normal

Normal Diminished

Normal Absent

Normal Absent

Retention, bladder stone

Diminished

Weak

Normal

Retention Frequency urge incontinence,

Absent Diminished sensation

Absent Normal

Absent Normal

unorgasmic

2. Urodynamic findings

Cystometrogram Filling Pressure

Involuntary Detrusor Contractions

Uroflow (max./av.)

Voiding Cystourethrogram Obstructed flow, no vesicoureteral reflux Obstructed flow, no vesicoureteral reflux Refused

200

27

60

8.9/1.9

2

300

6

55

0

4

5 6

7a 7b

7c 8

75-150

Refused cystometrogram 15

Anal Tone Control

Normal Normal Normal

1

3

Bulbocavemosus Reflex

Frequency urge incontinence Retention, impotence Retention, unable to ejaculate Retention Retention, impotence

TABLE

Bladder Capacity

Perinea! Sensation

4/3 120

10/4.5

300 250

10 9

45 48

6.8/1.9 0

1,500 900 600

36 15 15

None 40 45

None None None

300

8

34

18/8

obtain normal tumescence but could not ejaculate. One woman reported anorgasmia. Physical and laboratory examination. All patients had a complete neurological examination before our evaluation. At evaluation 4 patients had normal neurological examinations aside from voiding and/or erectile dysfunction. Of the remaining 4 patients 1 was paraplegic, 2 had paraparesis of the lower extremities requiring walking with some assistance, and 1 complained of weakness and some sensory loss in the left leg. The neurourological examination was normal in 4 patients. In 2 patients perianal sensation was absent, anal tone was lax and the bulbocavernosus reflex was absent. In 2 patients the perianal sensation was diminished. Urinalysis and an IVP were normal in all patients. Urodynamic evaluation. The urodynamic results are shown in table 2. Six patients had findings consistent with detrusorexternal sphincter dyssynergia. Detrusor hyperreflexia was found in 2 patients, associated with coordinated sphincteric relaxation in 1 patient and sphincteric incontinence in 1. During the cystometrograms bladder capacity ranged from 100 to 900 ml. (mean 335) and filling pressures were normal in all patients. All patients had detrusor hyperreflexia with pressures 34 to 120 cm. water (mean 57 cm. water). The patients were aware of the involuntary detrusor contractions that they sensed as an urge to void but could not abort them. On a voiding cystourethrogram 2 patients had a mildly trabeculated bladder. Otherwise, all were of normal configuration with a closed bladder neck at rest and no vesicoureteral reflux. Four patients had detrusor-external sphincter dyssynergia documented by electromyography, while 1 refused to undergo electromy-

Obstructed flow, no vesicoureteral reflux Normal Obstructed flow, no vesicoureteral reflux None Normal Obstructed flow, no vesicoureteral reflux Normal

Electromyography Not done Detrusor-extemal sphincter dyssynergia type 3 Refused Detrusor-extemal sphincter dyssynergia type 1 Poor recruitment Detrusor-external sphincter dyssynergia type 3 Not done Poor recruitment Detrusor-external sphincter dyssynergia Normal

ography but the radiographic appearance of the urethra during an involuntary detrusor contraction to 60 cm. water was diagnostic of detrusor-external sphincter dyssynergia. In a 37-yearold man with no urological history detrusor-external sphincter dyssynergia was suggested by the decreased uroflow but the patient refused a full urodynamic evaluation. In 1 man electromyography was of poor recruitment, potentials were predominantly polyphasic and sphincteric insufficiency was suggested, since the patient had stress incontinence despite a closed bladder neck on a voiding cystourethrogram. One patient had normal relaxation of the external sphincter during the involuntary bladder contraction and she generated good flow. Uroflow studies were obtained in all patients and were abnormally low in 7. In 1 patient (patient 7 in table 2) the initial urodynamic evaluation was performed 3 weeks after transverse myelopathy developed at LI to L2. This study revealed an acontractile detrusor even at 1,500 ml. bladder capacity and it was associated with physical findings of a complete lower motor neuron lesion. Followup urodynamic evaluations 10 and 17 weeks later revealed decreased vesical capacity to 900 and 600 ml., respectively. These further studies also documented the development of detrusor-external sphincter dyssynergia and persistence of physical neurourological abnormalities aside from the recovery of normal anal tone. Followup. Followup ranged from 6 months to 3 years. Four patients were on intermittent self-catheterization and anticholinergic medications. One man still was voiding with poor flow when he was lost to followup. The 2 women complained of urge incontinence and 1 was placed on anticholinergic therapy. The incontinence resolved but they continue to have some urinary

URINARY DYSFUNCTION IN TRANSVERSE l\,l:YEL!TIS

frequency and urgency. Patient 5 continued to ha_ve _stress and urge incontinence but the main concern was erectile nnpotence and he was lost to followup. DISCUSSION

Previously, all lesions involving the spinal cord were termed myelitis. With increased understanding of the underlying neuropathophysiology, only true spinal inflammatory p~ocesses are designated myelitis. Myelitis is classified further either by the duration of the progression of the symptoms (acute, subacute or chronic) or by the etiology (viral, bacterial, parasitic, tuberculosis and idiopathic). These disorders may selectively affect different parts of the nervous system, spinal cord and meninges (meningomyelitis) or meninges and roots (m~ningo:3:diculitis!. The inflammatory distribution is termed pohomyehtis when 1t is confined to the gray matter and leukomyelitis if it is within the white matter. When the entire thickness of the spinal cord is involved it is called transverse myelitis. 1 The neurological events during normal micturition that culminate in a detrusor contraction and urethral relaxation are integrated in the rostral brain stem in ~n are_a ~esignate~ as the pontine micturition center. Any les10n w1thm the spmal cord, such as trauma, multiple sclerosis, myelodysplasia a~d myelitis that causes disruption of this pathway may result m detruso;-external sphincter dyssynergia. 5 If the disease process involves the sacral (S2 to S4) cord or roots a lower motor neuron lesion may occur as well, with pudenda! or parasympathetic dysfunction. When the thoracolumbar cord is affected sympathetic dysfunction may occur. . . . Ropper and Poskanzer reported ~heir e~pen~nce w1_t~ patients with transverse myelopathy. I~ their sene~ the 1mt1:1l complaints were divided into parasthesias (24 patients), pam that generally was interscapular (18) and bilateral leg_weakness (7). In 3 patients urinary retention was the presentmg symptom. In 7 patients the clinical presentation was a combin~tion of the aforementioned symptoms, most notably concomitant back pain with leg weakness or parasthesias. In 19 of these patients recent symptoms of infectious illnes~ :"er~ rep?rted, mainly of the respiratory system (10), n~nspec1fic viral disea~e (6), gastrointestinal complaints (1) or history of recent vacc1: nation (1) or chicken pox (1). Documented fever at the outseL was uncommon. The course of the initial illness was progressive in 36 patients and subacute in 5 in whom progressi?n of the symptoms occurred during 10 to 14 days. Eleve~ pati~nt~ had a hyperacute onset, with all symptoms appearmg ~1thm 12 hours and usually within l hour. The most reproducible physical finding was a loss of pinprick sensation, located commonly between T6 and Tl2. During followup three-quarters of the patients had sphincter disturbances consisting of urinary and sometimes fecal incontinence but no specific studies to evaluate the nature of these complaints were performed. The clinical manifestations of myelitis are a function of the specific neurological lesions and can be varied. The urologist commonly is called upon when the patient is in urinary retention or incontinent and an indwelling catheter might already have been introduced into the bladder. Often, once the patient begins ambulation a voiding trial is given and the _management then is dictated by symptoms. Nevertheless, relymg on symptomatology alone can be misleading and subtle_ blad~er ~bno 7malities may be overlooked unless a proper mvest1gat10n 1s pursued. 7 • 8 At the time of our evaluation ~ p~tients h~d. no residual neurological deficit and had normal fmdmgs on chmcal neurourological examination, yet 2 of them had detrusor-external sphincter dyssynergia. The remaining 4 patients had mod-

?2

105

erate to significant neurological impairment and evidence of incomplete or complete lower motor neuron lesions, including a nonfunctioning sphincter and stress urinary incontinence. In 7 of our patients urodynamic studies were not done at the early stage of the disease, so the progression of bladder dysfunction in these patients can be only contemplated. It is conceivable that the evolution of the vesical dysfunction that was documented in patient 7 occurred in the remainder of our patients (excluding patient 5) but it was not demonstrated due to the delay of the urodynamic evaluation. The management of these patients is dictated by the underlying pathophysiology as determined by neurourological studies. The goal is to maintain continence and protect the upper urinary tracts. Empirical treatment of patients with transverse myelitis and urinary symptomatology without a prior urodynamic evaluation should be condemned. More so, these patients may require periodically repeated urodynamic examinations, although routine electromyograms probably will not be necessary. Most of the patients afflicted with transverse myelitis and voiding problems probably will resume a normal voiding pattern once recovery is complete. In our series 75% of the patients with persistent bladder symptoms had detrusor-external sphincter dyssynergia. This is a serious condition with predisposition to urological complications. 9 Careful followup and treatment are essential in their care. Treatment options include detrusor paralysis with either anticholinergics, tricyclic antidepressant or augmentation enterocystoplasty and intermittent self-catheterization, or external sphincterotomy. In our opinion, the latter procedure should be reserved for male patients who are unable to perform intermittent self-catheterization. Of our patients 25% had detrusor hyperreflexia that could be treated with anticholinergics. In others an acontractile bladder may be observed and they may require clean intermittent catheterization for long periods. The observation of decreased bladder compliance, manifested by high filling pressures, may necessitate additional therapy with an anticholinergic medication. The finding of incontinence secondary to sphincteric incompetence presents a special problem. Clean intermittent catheterization will not keep these patients dry on many occasions and they may require insertion of an artificial sphincter. In women a pubovaginal sling is a viable surgical option. REFERENCES 1. Adams, R. D. and Victor, M.: Principles of Neurology, 3rd ed. New

York: McGraw-Hill Book Co., p. 673, 1985. 2. Lipton, H. L. and Teasdall, R. D.: Acute transverse myelopathy in ~dults. Arch. Neurol., 28: 252, 1973. 3. Blaivas, J.: Multichannel urodynamic studies. Urology, 23: 421, 1984. 4. Blaivas, J. G.: Sphincter electromyography. Neurourol. Urodynam., 2: 269, 1983. 5. Blaivas, J. G.: Management of bladder dysfunction in multiple sclerosis. Neurology, 30: 12, 1980. 6. Ropper, A. H. and Poskanzer, D. C.: The prognosis of acute and subacute transverse myelopathy based on early signs and symptoms. Ann. Neurol., 4: 51, 1978. 7. Blaivas, J. G., Scott, R. M. and Labib, K. B.: Urodynamic evaluation as a neurologic test of sacral cord function, Urology, 13: 682, 1979. 8. Blaivas, J. G. and Katz, G. P.: The role of urodynamic testing in evaluating subtle neurologic lesions. In: Proceedings of the International Continence Society, Leiden, The Netherlands, pp. 43-45, 1982. 9. Blaivas, J. G. and Barbalias, G. A.: Detrusor-external sphincter dyssynergia in men with multiple sclerosis: an omnious urological condition. J. Urol., 131: 91, 1984.