Autonomic dysreflexia severity during urodynamics and cystoscopy in individuals with spinal cord injury

Abstract

Study Design: Retrospective chart review. Objective: To compare autonomic dysreflexia (AD) severity during urodynamics and cystoscopy in individuals with spinal cord injury (SCI). Setting: Outpatient urological clinic. Methods: Demographic and clinical data were collected from charts of individuals with SCI who had blood pressure (BP) monitoring during urological procedures. Cardiovascular parameters were collected at baseline and during the various stages of two examinations. Results: A total of 21 SCI individuals (mean age 49.4 years) who underwent both procedures developed episodes of AD. The majority of individuals had cervical SCI (85.7%). The median duration of injury was 183 months (ranging from 3 to 530 months). There was statistically more of an increase (P ¼ 0.039) in systolic BP during cystoscopy (67.1 ± 33.8 mm Hg) in comparison with urodynamics (51.8±21.8 mm Hg). The BP response during episodes of AD was more pronounced in individuals with more than 2 years post SCI than with less than 2 years post SCI during both urodynamics and cystoscopy (P ¼ 0.047 and P ¼ 0.010, respectively). Conclusion: Even though cystoscopy filled the bladder to lesser volumes than did urodynamics (150 ml vs 500 ml), during cystoscopy the individuals developed greater changes in systolic BP, indicating that stimulation of the urethra/prostate/internal sphincter region probably is a more potent stimulus of AD than just the filling of the bladder. The severity of AD also increased with time post SCI during both procedures. Considering the high incidence of silent episodes of AD during the urological procedures, it is recommended that monitoring of cardiovascular parameters during these procedures be routinely performed. One of the most common physician-induced causes of AD in individuals with SCI is the use of procedures that involve urinary bladder and urogenital areas. 3 Previously, numerous studies using different groups of individuals with SCI examined CV responses either during urodynamic 3-6 or cystoscopic examination. 7,8 These two procedures both involve urinary bladder distension. However, cystoscopy includes greater stimulation of the urethra and bladder neck afferents during the procedure through urethral/prostate/ internal sphincter passage and dilation, which could then provide more intense afferent stimulation to the spinal cord and trigger more pronounced episodes of AD. Considering the physiological difference

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review

“…One study 26 used both of these indicators. In the studies using SBP changes, the criteria varied from 10 to 50 mm Hg, whereas only three studies 24,25,34 published after 2009 used 20 mm Hg as the criteria, consistent with the ISAFSCI guidelines. Thus the use of the criteria from ISAFSCI should be encouraged in the future to make comparisons between studies easier.…”

“…Vespasiani et al 46 reported that 3 out of the 17 individuals presented signs and symptoms of AD during ballistic lithotripter. Liu et al 34 reported that the severity of AD increased with time following SCI, as demonstrated by a more pronounced SBP increase in individuals with SCI for 42 years compared with those with SCI for o2 years. In addition, no difference in SBP increase was found between symptomatic AD and asymptomatic AD individuals, as well as between complete and incomplete individuals during cystoscopy.…”

“…Linsenmeyer et al 16 found no correlation of AD with the duration of SCI. However, Liu et al 34 revealed that the severity of AD increased with time after SCI, as SBP increases were more pronounced in individuals with SCI for 42 years than in those with SCIo2 years.…”

“…Liu et al 34 reported that during cystoscopy SCI individuals developed greater changes in SBP than urodynamics (67.1 ± 33.8 vs 51.8 ± 21.8 mm Hg), indicating that stimulation of the urethra/prostate/internal sphincter region probably is a more potent stimulus of AD than just the filling of the bladder. Faaborg et al 44 showed that SBP increased less during transanal irrigation (36 mm Hg, range 30-63) than during digital evacuation (57 mm Hg, range 41-75) or filling cystometry (61 mm Hg, range 55-100)-the SBP response between digital evacuation and filling cystometry was insignificant.…”

“…Most studies 17,21,[23][24][25]33,34,41,44 used BP changes as the criteria, whereas some studies 15,16,39 used maximal BP as the criteria. One study 26 used both of these indicators.…”