Prognostic Value of Urodynamic Testing in Myelodysplastic Patients

Abstract

We herein describe the clinical progress of 42 myelodysplastic patients studied urodynamically and followed for a mean of 7.1 years. Urodynamic evaluation included urethral pressure profilometry, simultaneous determination of urethral pressure, intravesical pressure and external anal or external urethral sphincter electromyography with fluoroscopic voiding cystourethrography. Assessment of urethral function showed 36 patients (86 per cent) with an open vesical outlet and nonfunctional proximal urethral. Cystometrography revealed that 7 of 42 patients (17 per cent) had reflex detrusor activity: 4 with coordinated micturition and 3 with detrusor-sphincter dyssynergia. Thirty-five patients (83 per cent) had areflexic detrusor dysfunction: 5 with atomic detrusor response and 30 with a progressive increase in pressure with increasing volume. The intravesical pressure at the time of urethral leakage was 40 cm. water or less in 20 patients and at pressures greater than this value in 22 patients. No patient in the low pressure group had vesicoureteral reflux and only 2 showed ureteral dilatation on excretory urography. In contrast, of the patients in the higher pressure group 15 (68 per cent) showed vesicoureteral reflux and 18 (81 per cent) showed ureteral dilatation on excretory urography. Thus, a striking relationship between the urethral closure pressure and intravesical pressure at the time of urethral leakage and the clinical course in this group of myelodysplastic patients is demonstrated. Every patient with a normally closed vesical outlet was continent on intermittent catheterization and an anticholinergic agent, while only 60 per cent of patients with open bladder outlets similarly treated achieved good urinary control and none was dry. An artificial sphincter device would seem to be a reasonable method to achieve urinary control in the latter patients but the detrusor response to filling also must be considered. Detrusor hypertonia should be controlled or controllable before a sphincter augmenting device can be used safely. Treatment options for patients with high urethral closure pressures include intermittent catheterization and anticholinergic medications or a sphincter ablative procedure to decrease the outlet resistance combined with anticholinergic therapy and implantation of an artificial sphincter. However, only longer followup will determine if these therapeutic regimens will prevent upper urinary tract deterioration.

Urodynamic patterns after traumatic spinal cord injury

“…McGurie et al 22 Samson et al 15 said that a highly compliant bladder is associated with hyporeflexive or areflexive bladder as seen in lower motor neuron injuries, which is in close agreement to the findings in our study in which 37 (88%) patients with low bladder compliance had either DO or detrusor sphincter dyssynergia. But our findings do not match with the findings of Weld and Dmochowski, who demonstrated a higher frequency of impaired compliance in the sacral injury group, which can be explained on the basis of a relatively smaller sample size in our study.…”

“…All complications of untreated external detrusor sphincter dyssynergia result from high intravesical pressure prior to urinary leakage. As is recommended by McGurie et al 22 the pressure must be <40 cmH 2 O in a neurogenic bladder to minimize upper tract damage. Weld and Dmochowski 10 and Kaplan et al 12 concluded that detrusor sphincter dyssynergia is a common occurrence in supra sacral spinal cord lesions.…”

“…But our findings do not match with the findings of Weld and Dmochowski, who demonstrated a higher frequency of impaired compliance in the sacral injury group, which can be explained on the basis of a relatively smaller sample size in our study. 10 Hackler et al 21 and McGurie et al 22 have correlated low bladder compliance with upper tract complications and decreased upper tract function. A poorly compliant bladder increases the ureteral workload and compromises upper tract drainage.…”

Quality of Life after Active Urological Management of Chronic Spinal Cord Injury in Eastern Taiwan

“…Upper urinary tract deterioration depends upon the urethral leaking pressure and intravesical condition [6]. Functional bladder outlet obstructions caused by AD, DESD or a nonrelaxing external sphincter result in high intravesical pressure and large residual urine.…”

“…The risk factors that predispose the patient to renal deterioration include complete neurological lesions, cervical lesions with quadriplegia, and prolonged indwelling catheters [7, 8, 9, 10]. Regular determination of intravesical pressure, residual urine and leak point pressure can provide information to avoid upper tract deterioration [6, 11]. For patients with urinary incontinence a poorly compliant bladder should be searched for.…”