Autonomic dysreflexia during urodynamics

Abstract

Autonomic dysre¯exia (AD) is an acute syndrome characterised by inappropriate and massive autonomic response that occurs in patients with spinal cord injury above the T6 level. Aims: to evaluate the incidence of AD during cystometry and the relationships with clinical and urodynamic features. Patients and methods: Forty-eight spinal cord injury patients were studied by neurological and urological examination and urodynamic evaluation with concurrent recording of blood pressure, heart rate and symptoms and signs of AD. Patients were considered to have AD if blood pressure reached values higher than 150/100 mmHg. Results: All the patients showed a signi®cant increase of both systolic and diastolic blood pressure, although only 20 showed pressure values higher than 150/100 mmHg (in seven of them without AD symptoms). AD was more frequent in cervical patients (P=0.034), but did not correlate with any other clinical features: sex ratio, age, disease duration, completeness of lesion, incidence of detrusor hyperre¯exia/are¯exia and detrusor-sphincter dyssynergia, voiding modalities, usage of anticholinergic drugs. In three patients blood pressure increase began when uninhibited contraction started, in 11 it was coincident with unhibited contraction peak and in the other six it appeared at maximum bladder capacity. Conclusions: (1) during urodynamic evaluation all the patients with lesion level above T6 showed signs of sympathetic stimulation, although only some showed dangerous blood pressure values; (2) the relationship between urodynamic data and dysre¯exia crisis shows that both the presence of detrusor uninhibited contractions and bladder distension are able to stimulate the crisis; (3) treatment with anticholinergic drugs is not sucient to prevent autonomic dysre¯exia starting from the bladder, unless it induces detrusor are¯exia. These patients are at risk of developing autonomic dysre¯exia following bladder distension.

Blood pressure and age associated with silent autonomic dysreflexia during urodynamic examinations in patients with spinal cord injury

“…Moreover, two of these studies mentioned that some patients in the group that they defined as normotensive showed AD symptoms. 6,9 No one in the non-AD group in the present study had any AD symptoms. Both this study and the previous report by Linsenmeyer et al 6 reveal that the absolute levels of BP is not crucial to symptomatic presentation.…”

“…This percentage of silent AD is higher than three previous studies that reported 35, 38 and 43% respectively. 6,8,9 This discrepancy may be due to the different criteria of AD in these studies. Two of them used definite levels of SBP/DBP values as 160/100 and 150/100 mmHg, respectively, whereas one used an SBP increment percentage of 30% of baseline value.…”

“…9 As elevation of BP during UD examination is a gradual but continuous pattern, it is difficult to determine the beginning or onset of BP increment. By comparing SBP difference before and after each UD event, this study reveals that the most prominent changes in SBP elevation occur at the onsets of DC and DSD.…”

“…3,[6][7][8][9] Some of these have also found that the proportion of patients presenting with silent AD ranges from 35 to 43%. 6,8,9 However, only one, the study by Linsenmeyer et al, 6 investigated the differential variables between symptomatic and silent AD. They found that no factor was significant, including BP values, levels of neurologic injury, length of injury, voiding pressures and bladder capacity.…”

Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury

“…A number of studies examined the AD reaction during urodynamic evaluation 9,10 and actual bowel program. 11,12 Our group previously investigated the AD responses before, during and after a bowel program involving manual removal of stool in lateral recumbency in patients with cervical SCI.…”