Significance of detrusor compliance in patients with localized partial lesions of the spinal cord and cauda equina

Neurogenic bladder in patients with paraplegia: a two-center study of the real-life experience of the patients' journey

INTRODUCTION

Several patterns of urological dysfunctions have been described following spinal cord injury (SCI), depending on the level and the completeness of the injury. A better understanding of the natural history of neurogenic bladder in patients with SCI, and the description of their successive therapeutic lines based on their clinical and urodynamic pattern is needed to improve their management. This study aimed to describe the real-life successive therapeutic lines in patients with neurogenic lower urinary tract dysfunction (NLUTD) following SCI.

METHODS

We conducted a two-center retrospective review of medical files of patients with SCI followed in two French specialized departments of Physical Medicine and Rehabilitation between January 2000 and January 2018. All patients with SCI with a level of lesion bellow T3 and older than 18 years old were eligible. The primary outcome was the description of the natural journey of neurogenic bladder in this population, from the awakening bladder contraction to the last therapeutic line. Survival curves were calculated with a 95-confidence interval using the Kaplan-Meier method.

RESULTS

One hundred and five patients were included in this study. Most of the patients were young men with a complete SCI lesion. The median time of treatment introduction was 1 and 9 years for anticholinergics and intradetrusor injection of BoNT/A, respectively. Median duration of effect of treatments was 4 and 6 years post-introduction of anticholinergics and BoNT/A, respectively.

CONCLUSION

This study describes NLUTD journey of patients with SCI demonstrating the mid-term efficacy of the two first therapeutic lines of NDO management. An improvement of non-surgical therapeutics is needed.

Control of detrusor stiffness in the chronic decentralized feline bladder

The neuropharmacology of increased bladder stiffness, which may contribute to upper tract damage and incontinence, was investigated in 76 cats. beta-blockade increased but combined alpha 1-adrenergic with muscarinic blockade decreased filling phase stiffness in normal cats. Bladder wall stiffness during the early filling phase was unaffected by chronic S2 ventrodorsal rhizotomy or L7-S3 ventral rhizotomy, but was decreased when L7-S3 dorsal rhizotomy or total sympathectomy was combined with the ventral root lesion, implying that sacral dorsal roots and sympathetic efferents maintain normal detrusor stiffness. Acute sympathectomy increased stiffness in all the former 3 chronic groups, implying that a tonic or reflex sympathetic inhibition operates independently of the L7-S3 dorsal roots. Stiffness during early filling phase decreased with acute ventral rhizotomy. This change persisted with chronic sympathectomy but returned to normal if sympathetic nerves were left intact. These results suggest that bladder stiffness is modulated by tonic or reflexic sympathetic activity, which is influenced by L7-S3 afferents. Detrusor stiffness during the later stages of filling, which was decreased by acute sympathectomy in chronic groups but increased by chronic sympathectomy, was reduced by interference with adrenergic or muscarinic mechanisms after either lesion. Therefore, a peripheral pathway with facilitatory alpha 1-adrenergic and muscarinic receptors is involved in the production of increased late stage stiffness after chronic sympathetic damage. We propose that the increased bladder stiffness seen in congenital sacral lesions may be analogous to the stiffness during late stages of filling reported here. Our results also imply that the presence of this increased stiffness is closely associated with chronic sympathetic damage. Whether the increased stiffness in congenital and traumatic neural lesions in humans arises from sympathetic damage remains to be determined.

Detrusor hyperreflexia in neurogenic bladder disorders caused by localized partial lesions of the spinal cord and cauda equina

In 70 patients studied by cystometry, detrusor hyperreflexia seen with localized partial lesions of the spinal cord and cauda equina could be differentiated into two types. In one type, in which the hyperreflexia was of a reflex nature and bladder compliance was unchanged, the detrusor contractility was described as compliant hyperreflexic. In the other type, in which the contractions were of a rhythmic nature and accompanied by reduced compliance, the contractility of the detrusor was described as noncompliant hyperreflexic. The compliant hyperreflexic contractions correlated well with signs of upper motor neuron disturbance, the noncompliant hyperreflexic contractions with lower motor neuron disturbance.