URODYNAMf CS
LOWER URINARY TRACT DYSFUNCTION IN MULTIPLE SCLEROSIS MICHAEL MICHAEL
E. MAYO, M.B.B.S. P CHETNER, M.D.
From the Department of Urology, University School of hiledicine, Seattle, Washington
of Washington
___~_ ___.__ ABSTRACTPrevious investigator,y have shown that in multiple srlerosis fuilure to empty the bladder was secondary to detrusor-distal qsphinctcjr dyss!ynergia or areflexia. However, our urodynamic evaluation of 46female and 4J male patients with multiple sclerosis revealed that 63 percent of patients failed to empty their bladder,y because of a hypocontractile detrusor, and only 6 ,I.WFcent had areflexia. Detrusor-distal sphincter dyssynergia (6 5%) and bladder neck obstruction (6 !%) were present in only 12 percent of patients. Hypcrrcflexia was common (78 %)) and was associated with hypocontractility in 63 per-rent of patients. Urgency incontinence u’as significantly more common in females and voiding difficulty significantly more common in males. Sensation u:us also reduced in 74 percent of fernale und 77 percent of male pa ticn ts. Ir, conclusion, failure to empty the bladder in multiple sclerosis is most commonhy of hyperreflexiu anti as.vociated with hypocontractility, and the combination hypocontractilitzl produces the ,symptom.s of. urgency and incomplete emptyirq. . ”
Lower urinaqr tract symptoms occur in up to 90 percent of multiple sclerosis patients at some time in the course of their disease.’ Detrusor hyperreflexia and distal sphincter dyssynergia are the most commonly reported urodynamic findings.’ 4 However, Gonor, Carroll, and Metcalfe’ reported that although 78 percent of their patients had hyperreflexia, 50 percent of these had hypocontractility with voiding, and only 12 percent had dyssynergia. Preliminary review of our patients with multiple sclerosis also revealed that hypocontractility not only co-existed with hyperreflexia but was also the commonest cause for incomplete bladder emptying. Material
and Methods
Eighty-nine patients with multiple sclerosis and bladder symptoms were referred for urodynamic evaluation. Patients were asked to come for the study with a full bladder so that a preliminaqflow rate, voided volume, and initial postvoid residual could be obtained. This was followed b>, a filling and voiding study
I~HoI,o(:l
JANUARY
1992
VOI,UME
N?XlX.
measuring bladder, rectal, and detrusor pressures with perianal needle electron-lyogral,h\: Flow rate was recorded if the patient was able to sit in the voiding chair. The bladder was filled at 25 to 50 mL per minute with contrast solution and fluoroscopy performed intermittently during filling and voiding. The final postvoid residual was estimated b:!, subtracting the voided volume from the capacit!; .4nalyses were performed with the x2 test with Yates’ correction. Results There were 46 females and 43 nlales Lvith an age range of twenty-two to seventy-one years (median 48 yrs.). Multiple sclerosis had been present for one-half to thirty-five \‘ears (median 12 yrs.) and bladder symptoms for one-half to twenty-five years (median 4 yrs.). The severit!. of the disease was variable, but 50 percent of the patients were using wheelchairs. The prevalence of various symptoms are shown in Table I. Urgency and urgency incontinence were significantly more common in females. althollgh
NUMHEH 1
67
24
fMIMk
y/O
lW.S. 6 mos.
Initial PVR
60
ml.
Capacity
50
ml.
PInal
PVR
0 ml.
FIGURE 1.
Patient had hyperreflexia with complete emptying during the study; capacity was less than initial postvoid residual (PVR); therefore bladder was artificially stimulated. Patient therefore normally has hypocontractile detrusor.
50
Detru,or Pressure (Cm. water)
0
1
hyperreflexia was present equally in females (77%) and in males (78%). Hesitancy was significantly more common in males. Failure to empty the bladder was due to a variety of causes that were defined as follows: 1. An acontractile detrusor was present when no significant pressure rise (< 10 cm water) occurred during filling or voiding.
TAHI.E I.
Prevalence
Symptom Frequenq Urgenq Urge incontinence Difficult! Urinary tract infection
of symptoms
Male No.(%)
Female No.(%)
20 25 19 31 7
31 38 32 19 10
(4’7) (58) (44) (72)’ (16)
(67) (83)* (70)’ (41) (22)
Total No.(%) 51 (57) 63 (71) 51 (57) SO (56) 17 (19)
TABI.R II.
Hyperreflexia Emptying failure Acontractile Hypocontractile Detrusor sphincter dyssynergia Bladder neck obstruction Indeterminate findings Efficient voiding Hyperreflexia and hypocontractility
68
2. Detrusor hypocontractility was failure to empty the bladder associated with a detrusor pressure that was low or faded during voiding. Hypocontractility was also said to be present when there was evidence that the detrusor was easily stimulated even at the relatively slow filling rate of 25 to 50 mL per minute. In this situation, voiding during the study was more efficient and the final residual was either reported that 78 percent of their patients with multiple sclerosis had hyperreflexia and of these, SO percent had hypocontractility and 12 Ijercent had dyssynergia. We agree that the combination of hyperreflexia producing urgency’ and hy.pocontractility leading to bladder-emptying failure is common in this disease. Of the 69 patients with hyperreflexia, 56 (81%) had hypocontractility, and the difference between this and the FiOpercent in Gonor et al.” series may’ be in the definition of hypocontractility. We believe that the final postvoid residual may bc artificially low because, in multiple sclerosis. thr, detrrwor was easily stimulated by the circumstances of the study even w,hen the filling rate w’as k(q,t as low as 25 to 50 mL, per minutch. Hypocontractilityr in mriltiple sclerosis may. be the result of a peripheral ncrrropathy~. (:II ct ~1.” demonstrated an increase in a Schw.amr cell marker in the bladder tissue of multiple sclerosis patients indicating neuronal I:lern!elination at that level. Moss, Tansey, and Rrrrnstock’ in an experimental study of clew!-~1iIlution in mice, demonstrated changes in the purinergic transmission in the bladder, but it is not clear vvhether it is specific for demvt+rration or a change associated with hypertr&>h!; ot the, detrusor. Although reflux and upper trac:t change:, can occur in multiple sclerosis, the\, art’ rare (2 % to 3% ) when compared with patients vvith spinal cord injury where the prevalence is 13 percent bladder to 20 percent. H$’Similarly: significant
trabeculation in our series was present in only 12 percent of patients compared with its prevalence in patients with spinal cord injury (57% in multiple to 70%).6 ‘O Hypocontractility sclerosis seems to protect the bladder and upper urinary tracts but may lead to management problems. Although intermittent self-catheterization would seem to be ideal, few patients have enough upper limb strength or coordination to achieve this. of Urology, RL-10 University of Washington School of Medicine Seattle, Washington 98195 (DR. MAYO)
Department
References 1. McGuirc EJ, and Savastano JA: Urodynamic findings and long-term outcome management of patients with multiple sclero-
70
sis-induced louver urinary tract dysfunction, J Ural 132: 102 (1984). 2. Awad SA. cf al: Relationships between neurological and urological status in patients with multiple sclerosis, J Urol 132: 499 (1984). 3. Goldstein I. ct ul: Neurological ahnormalities in multiple sclerosis. J Urol 128: 541 (1982). 4. Blaivas JC, Bhimani C, and Labib KB: Vcsicourethral dysfunction in multiple sclerosis. J Urol 122: 342 (1979). 5. Gonor SE, Carroll DJ, and Metcalfe JB: Vcsical dyfunction in multiple sclerosis, Uroloa 25: 429 (1985). 6. Gu J, ct al: Increase of S-100 immunorcactivity in the urinary bladder from patients with multiple sclerosis, an indication of peripheral neuronal lesion, Am J Clin Path01 82: 649 (1984). 7. .Moss IIE. Tansy EM, and Burnstock 6: Ahnormalities of responses to autonomic stimulation in the mouse urinary bladder associated with semliki forest virus-induced demyelination, J Urol 142: 850 (1989). 8. Anderson RU: Urodynamic patterns after acute spinal cord injury: association with bladder trabcculation in male patients, J Ural 129: 777 (1983). 9. Hoffberg JH, and Cardenas DD: Bladder traheculation in spinal cord injury, Arch Phys Mcd Rehabil 67: 750 (1986). 10. Newman E, and Price M: External catheters: hazards and Benefits of their use by men with spinal cord lesions. Arch Phys Mcd Rehabil 66: 310 (198.5).
UROI,OGY
/ JANUARY 1992
/ VOLUME
XXSIS,
NUhlBER
1
LOWER URINARY TRACT DYSFUNCTION IN MULTIPLE SCLEROSIS MICHAEL MICHAEL
E. MAYO, M.B.B.S. P CHETNER, M.D.
From the Department of Urology, University School of hiledicine, Seattle, Washington
of Washington
___~_ ___.__ ABSTRACTPrevious investigator,y have shown that in multiple srlerosis fuilure to empty the bladder was secondary to detrusor-distal qsphinctcjr dyss!ynergia or areflexia. However, our urodynamic evaluation of 46female and 4J male patients with multiple sclerosis revealed that 63 percent of patients failed to empty their bladder,y because of a hypocontractile detrusor, and only 6 ,I.WFcent had areflexia. Detrusor-distal sphincter dyssynergia (6 5%) and bladder neck obstruction (6 !%) were present in only 12 percent of patients. Hypcrrcflexia was common (78 %)) and was associated with hypocontractility in 63 per-rent of patients. Urgency incontinence u’as significantly more common in females and voiding difficulty significantly more common in males. Sensation u:us also reduced in 74 percent of fernale und 77 percent of male pa ticn ts. Ir, conclusion, failure to empty the bladder in multiple sclerosis is most commonhy of hyperreflexiu anti as.vociated with hypocontractility, and the combination hypocontractilitzl produces the ,symptom.s of. urgency and incomplete emptyirq. . ”
Lower urinaqr tract symptoms occur in up to 90 percent of multiple sclerosis patients at some time in the course of their disease.’ Detrusor hyperreflexia and distal sphincter dyssynergia are the most commonly reported urodynamic findings.’ 4 However, Gonor, Carroll, and Metcalfe’ reported that although 78 percent of their patients had hyperreflexia, 50 percent of these had hypocontractility with voiding, and only 12 percent had dyssynergia. Preliminary review of our patients with multiple sclerosis also revealed that hypocontractility not only co-existed with hyperreflexia but was also the commonest cause for incomplete bladder emptying. Material
and Methods
Eighty-nine patients with multiple sclerosis and bladder symptoms were referred for urodynamic evaluation. Patients were asked to come for the study with a full bladder so that a preliminaqflow rate, voided volume, and initial postvoid residual could be obtained. This was followed b>, a filling and voiding study
I~HoI,o(:l
JANUARY
1992
VOI,UME
N?XlX.
measuring bladder, rectal, and detrusor pressures with perianal needle electron-lyogral,h\: Flow rate was recorded if the patient was able to sit in the voiding chair. The bladder was filled at 25 to 50 mL per minute with contrast solution and fluoroscopy performed intermittently during filling and voiding. The final postvoid residual was estimated b:!, subtracting the voided volume from the capacit!; .4nalyses were performed with the x2 test with Yates’ correction. Results There were 46 females and 43 nlales Lvith an age range of twenty-two to seventy-one years (median 48 yrs.). Multiple sclerosis had been present for one-half to thirty-five \‘ears (median 12 yrs.) and bladder symptoms for one-half to twenty-five years (median 4 yrs.). The severit!. of the disease was variable, but 50 percent of the patients were using wheelchairs. The prevalence of various symptoms are shown in Table I. Urgency and urgency incontinence were significantly more common in females. althollgh
NUMHEH 1
67
24
fMIMk
y/O
lW.S. 6 mos.
Initial PVR
60
ml.
Capacity
50
ml.
PInal
PVR
0 ml.
FIGURE 1.
Patient had hyperreflexia with complete emptying during the study; capacity was less than initial postvoid residual (PVR); therefore bladder was artificially stimulated. Patient therefore normally has hypocontractile detrusor.
50
Detru,or Pressure (Cm. water)
0
1
hyperreflexia was present equally in females (77%) and in males (78%). Hesitancy was significantly more common in males. Failure to empty the bladder was due to a variety of causes that were defined as follows: 1. An acontractile detrusor was present when no significant pressure rise (< 10 cm water) occurred during filling or voiding.
TAHI.E I.
Prevalence
Symptom Frequenq Urgenq Urge incontinence Difficult! Urinary tract infection
of symptoms
Male No.(%)
Female No.(%)
20 25 19 31 7
31 38 32 19 10
(4’7) (58) (44) (72)’ (16)
(67) (83)* (70)’ (41) (22)
Total No.(%) 51 (57) 63 (71) 51 (57) SO (56) 17 (19)
TABI.R II.
Hyperreflexia Emptying failure Acontractile Hypocontractile Detrusor sphincter dyssynergia Bladder neck obstruction Indeterminate findings Efficient voiding Hyperreflexia and hypocontractility
68
2. Detrusor hypocontractility was failure to empty the bladder associated with a detrusor pressure that was low or faded during voiding. Hypocontractility was also said to be present when there was evidence that the detrusor was easily stimulated even at the relatively slow filling rate of 25 to 50 mL per minute. In this situation, voiding during the study was more efficient and the final residual was either reported that 78 percent of their patients with multiple sclerosis had hyperreflexia and of these, SO percent had hypocontractility and 12 Ijercent had dyssynergia. We agree that the combination of hyperreflexia producing urgency’ and hy.pocontractility leading to bladder-emptying failure is common in this disease. Of the 69 patients with hyperreflexia, 56 (81%) had hypocontractility, and the difference between this and the FiOpercent in Gonor et al.” series may’ be in the definition of hypocontractility. We believe that the final postvoid residual may bc artificially low because, in multiple sclerosis. thr, detrrwor was easily stimulated by the circumstances of the study even w,hen the filling rate w’as k(q,t as low as 25 to 50 mL, per minutch. Hypocontractilityr in mriltiple sclerosis may. be the result of a peripheral ncrrropathy~. (:II ct ~1.” demonstrated an increase in a Schw.amr cell marker in the bladder tissue of multiple sclerosis patients indicating neuronal I:lern!elination at that level. Moss, Tansey, and Rrrrnstock’ in an experimental study of clew!-~1iIlution in mice, demonstrated changes in the purinergic transmission in the bladder, but it is not clear vvhether it is specific for demvt+rration or a change associated with hypertr&>h!; ot the, detrusor. Although reflux and upper trac:t change:, can occur in multiple sclerosis, the\, art’ rare (2 % to 3% ) when compared with patients vvith spinal cord injury where the prevalence is 13 percent bladder to 20 percent. H$’Similarly: significant
trabeculation in our series was present in only 12 percent of patients compared with its prevalence in patients with spinal cord injury (57% in multiple to 70%).6 ‘O Hypocontractility sclerosis seems to protect the bladder and upper urinary tracts but may lead to management problems. Although intermittent self-catheterization would seem to be ideal, few patients have enough upper limb strength or coordination to achieve this. of Urology, RL-10 University of Washington School of Medicine Seattle, Washington 98195 (DR. MAYO)
Department
References 1. McGuirc EJ, and Savastano JA: Urodynamic findings and long-term outcome management of patients with multiple sclero-
70
sis-induced louver urinary tract dysfunction, J Ural 132: 102 (1984). 2. Awad SA. cf al: Relationships between neurological and urological status in patients with multiple sclerosis, J Urol 132: 499 (1984). 3. Goldstein I. ct ul: Neurological ahnormalities in multiple sclerosis. J Urol 128: 541 (1982). 4. Blaivas JC, Bhimani C, and Labib KB: Vcsicourethral dysfunction in multiple sclerosis. J Urol 122: 342 (1979). 5. Gonor SE, Carroll DJ, and Metcalfe JB: Vcsical dyfunction in multiple sclerosis, Uroloa 25: 429 (1985). 6. Gu J, ct al: Increase of S-100 immunorcactivity in the urinary bladder from patients with multiple sclerosis, an indication of peripheral neuronal lesion, Am J Clin Path01 82: 649 (1984). 7. .Moss IIE. Tansy EM, and Burnstock 6: Ahnormalities of responses to autonomic stimulation in the mouse urinary bladder associated with semliki forest virus-induced demyelination, J Urol 142: 850 (1989). 8. Anderson RU: Urodynamic patterns after acute spinal cord injury: association with bladder trabcculation in male patients, J Ural 129: 777 (1983). 9. Hoffberg JH, and Cardenas DD: Bladder traheculation in spinal cord injury, Arch Phys Mcd Rehabil 67: 750 (1986). 10. Newman E, and Price M: External catheters: hazards and Benefits of their use by men with spinal cord lesions. Arch Phys Mcd Rehabil 66: 310 (198.5).
UROI,OGY
/ JANUARY 1992
/ VOLUME
XXSIS,
NUhlBER
1
