Neuro-urological investigation in urinary bladder dysfunction

The importance of the clinical examination of the lower sacral segments: Four case reports

CONTEXT

In our practice, in a spinal cord injury unit, clinical examinations include anal sensation and voluntary anal contraction, which are essential for neurological classification of spinal cord injury according to international standards (ISNCSCI), but we also always examine the integrity of the sacral segments, testing anal tone and anal and bulbocavernosus reflexes (S2-S4 segments) and the dartos reflex to evaluate the thoracolumbar sympathetic pathway.

FINDINGS

In this paper, we describe four case reports of bladder dysfunction in which a clinical examination of the lower sacral segments was decisive to identify the neurological etiology.

CONCLUSION/CLINICAL RELEVANCE

These cases, in patients with unexplained bladder dysfunction, highlight the importance of clinical testing the sacral segments, as part of the neurological examination, otherwise sacral lesions may remain undetected.

Clinical Caveats on Medical Assessment and Treatment of Pain After TBI

The diagnosis and management of pain in the patient with traumatic brain injury (TBI) can be difficult in light of the limitations imposed by the cognitive, language, and behavioral deficits. With patients in the acute rehabilitation setting, one must be vigilant for the often subtle signs and symptoms of pain. Causes more commonly seen in the population with TBI as a consequence of the injury itself include dysautonomia, neuropathic pain, spasticity, and heterotopic ossification. Headaches may be a consequence of TBI or associated with it for other reasons. Sources of pain associated with TBI include deep venous thrombosis and others. The reader is reminded that patients with TBI are subject to all the causes of pain that affect the general population.

Disturbances of ano-rectal function in multiple sclerosis

Thirty patients with multiple sclerosis (MS) [18 men and 12 women, mean age 40 years (range 22-50), disease duration 12 years (range 0.5-34), Kurtzke's Expanded Disability Status Score 6.0 (range 4.0-7.5)] were interviewed about bowel symptoms and studied using ano-rectal manometry. The results were compared with findings in healthy controls. Twenty-eight had bowel symptoms: 8 constipation, 10 constipation and infrequent faecal urgency, 4 infrequent faecal incontinence and 6 frequent faecal incontinence. Anal sphincter pressure at rest was significantly reduced in MS patients 69 (SD 17) cm H2O, compared with 92 (SD 15) cm H2O in controls, and the external sphincter contraction force was also significantly reduced. Rectal sensation and rectal compliance were reduced and the ano-rectal inhibition reflex (defaecation reflex) required a higher rectal pressure to be elicited in the patients. Upon rectal filling, an early external sphincter excitation was seen. The presence of faecal incontinence correlated strongly with reduced rectal sensation. The findings suggest that faecal incontinence can at least partly be explained by low anal sphincter pressure and poor rectal sensation. The findings of early sphincter excitation and increased threshold of ano-rectal inhibition reflex may be an important pathophysiological factor for constipation in MS patients.

Diabetic cystopathy

Diabetic cystopathy refers to the spectrum of voiding dysfunction in patients with diabetes mellitus. Diabetic cystopathy is marked by insidious onset and progression with minimal symptomology. The most common urodynamic findings are impairment of bladder sensation, increased post-void residual volume, decreased detrusor contractility that may progress to detrusor areflexia and diminished urinary flow. Treatment of diabetic cystopathy may be complicated by frequently occurring coexisting urologic conditions. The most common of these is bladder outlet obstruction. Therefore, treatment of diabetic cystopathy should be tailored to the symptom complex and clinical condition of the patient. Asymptomatic patients with manifestations of diabetic cystopathy may be treated with timed voiding. In contrast, the sine qua non for therapy in symptomatic patients is clean intermittent catheterization. While other modalities such as pharmacologic and surgical intervention have been described, none have been consistently effective.

The conus demyelination syndrome in multiple sclerosis

Bowel, bladder and sexual dysfunction are common in multiple sclerosis and are generally attributed to the widespread nature of the involvement of the neuroaxis by the demyelinating plaques. Recently we encountered a specific subset of patients within this group who had characteristic clinical complaints of hesitancy, straining and incomplete voiding, perineal hypesthesia on examination, areflexia by cystometry and colonometry and electrophysiological parameters suggesting involvement of the conus medullaris. This heretofore postulated but undocumented mechanism of neurovisceral dysfunction in multiple sclerosis is detailed and discussed in 2 patients in this report.