Division of the External Sphincter¹

Abstract

Summary Division of the external sphincter may be required for obstruction at that level with or without evidence of spasticity. In supra‐sacral lesions with good detrusor contractions there is normally no indication for a bladder neck resection and, when necessary, external sphincterotomy can confidently be carried out as a primary procedure. In sacral lesions, bladder neck resection may be required as a substitute for the normal opening mechanism, and this may have to be followed by division of an obstructive but non‐spastic external sphincter region. The operation shows up favourably as regards simplicity, safety, effectiveness and freedom from complications when compared with the alternative procedures which have been suggested.

A 10 year review of the endoscopic treatment of 125 spinal cord injured patients with vesical outlet obstruction: does bladder neck dyssynergia exist?

“…He had also indicated that in the upper motor-neurone bladder with detrusor contractions there was normally no indication for a bladder neck resection and, when necessary external sphincterotomy can confidently be carried out as a primary procedure. 6 Ross and his co-workers performed external sphincterotomy on all patients whether with an upper or a lower motor neurone bladder, 7 while O'Flynn performed bladder neck resection as the primary operation irrespective of the type of bladder dysfunc tion, and if that failed an external sphincterotomy was performed. 8 Combined bladder neck resection and external sphinterotomy has been in practice at Meath Hospital, Dublin since 1971.…”

The long term results of transurethral division of the external urethral sphincter in the neuropathic urethra with reference to potency

“…We do not use a loop resectoscope electrode. The technique has been described in our reports (Gibbon, 1973). The effectiveness of the procedure upon the urethral pressure profile has been fully documented (Abel et ai., 1975).…”

The neuropathic urethra

“…Then Watkins (1936) reported finding obstruction at the level of the membranous urethra in patients with lesions of the sacral segments. Internal membranous urethrotomy (loosely called 'external sphincterotomy') was introduced for the relief of these cases (Ross et ai., 1957), and whilst it proved effective, the mechanism of the obstruction was obscure (Gibbon, 1973).About the same time Emmett et ai. (1948) noted the common occurrence of membranous urethral obstruction in spastic paraplegics and suggested its relief by subarachnoid alcohol block, sacral rhizotomy or pudendal neurectomy on the assumption that contraction of the striated muscle of the urethra or pelvic floor was responsible.…”

“…An obvious clue was the traditional belief that some paraplegics void more easily lying down that when sitting, and so the retrograde urethral resistance was measured in a series of paraplegics in the two positions. Assumption of the upright posture was associated with a marked increase of resistance in most of these patients whatever the level of the spinal lesion (Gibbon, 1973). The introduction of urethral pressure profilometry enabled the wall pressure along the urethra to be shown graphically and fresh light was soon shed on the problem by Donker's (1972) demonstration that in the normal subject a major part of the peak urethral resistance (at the level of the urogenital diaphragm) is due to muscle under alpha-adrenergic control.…”

“…Then Watkins (1936) reported finding obstruction at the level of the membranous urethra in patients with lesions of the sacral segments. Internal membranous urethrotomy (loosely called 'external sphincterotomy') was introduced for the relief of these cases (Ross et ai., 1957), and whilst it proved effective, the mechanism of the obstruction was obscure (Gibbon, 1973).…”