The various types of neurogenic bladder dysfunction: an update of current therapeutic concepts

Increased experience with treatment strategies developed during the last 10 years in the field of neurourology justifies an update of current therapeutic concepts. Based on a rather simple, but clinically useful, classification of detrusor-sphincter dysfunction the therapeutic concepts now available for four prototypes of detrusor-sphincter dysfunction are discussed. (1)For the combination of a hyperreflexive detrusor with a hyperreflexive (spastic) sphincter, characteristic for the reflex- and the uninhibited neuropathic bladder, detrusor sphincter dyssynergia (DSD) is still the greatest problem, and transurethral sphincterotomy is the method of choice if this situation cannot otherwise be managed. One concept is to convert detrusor hyperreflexia into hyporeflexia by adequate pharmacotherapy, which is nowadays available, and to assist or to accomplish bladder emptying by clean intermittent (self-) catheterisation (CIC) with the advantage of dry intervals in between. Japanese colleagues recommend bladder overdistension during the spinal shock phase to achieve detrusor hyporeflexia, but this procedure is rather decisive at an early stage of the disability, leaving the detrusor no chance for further rehabilitation. Another possibility is rhizotomy of the sacral posterior roots to eliminate detrusor hyperreflexia, and the simultaneous implantation of a sacral anterior root stimulator (Brindley) to achieve electrically induced micturition. From our personal experience with 12 patients this concept is ideal for female patients with unbalanced reflex bladder and otherwise uncontrollable reflex incontinence. (2)The combination of a weak detrusor with a spastic sphincter is a clear indication for CIC, as the bladder is emptied regularly, and due to the spastic sphincter, the patient stays continent as long as controlled fluid intake prohibits overflow incontinence. The implantation of an anterior sacral root stimulator is an alternative approach provided that at least weak reflex detrusor contractions are present. (3)With the combination of an areflexive or hyporeflexive detrusor and a flaccid pelvic floor, passive voiding by abdominal straining or by the Credé manoeuvre is usually recommended, but should be replaced by CIC if this mechanism of bladder emptying creates unphysiological high and dangerous intravesical pressures, or if vesicouretero-renal reflux is present. Neurogenic urinary stress incontinence is usually associated with this type of lesion and can be successfully treated by the implantation of an artificial urinary sphincter (Scott). However in two thirds of the patients with neurogenic bladder dysfunction, additional, usually operative treatment is necessary to meet the criteria for implantation. Moreover, a 30% rate of repair operations must be accepted by patients, but is becoming less frequently required with an improved design of the device. With conventional operations continence can only be achieved in those patients by maximal elevation of the bladder neck thus inducing bladder outflow obstruction requiring consequent CIC, but CIC may be difficult to perform due to the anatomical situation of a maximally elevated bladder neck. (4)If a hyperreflexive detrusor is combined with a weak sphincter, again urinary incontinence is the greatest problem. To begin with, elimination of detrusor hyperreflexia is mandatory and can often only be accomplished by surgery, either by bladder augmentation using an isolated detubularised segment ofileum serving as energy destroyer, or by sacral posterior root rhizotomy. Sometimes the elimination of detrusor hyperreflexia in combination with CIC provides a socially acceptable situation, but neurogenic urinary stress incontinence has to be treated by an artificial urinary sphincter. (5)Finally, in patients with incomplete spinal cord lesions intravesical electrotherapy (Katona, 1975), based on receptor depolarisation contributes greatly to the rehabilitation of the neuropathic bladder. In children with myelo- or sacral dysplasia this method together with biofeedback is an indispensible tool within a complex training programme for bladder rehabilitation. The increased therapeutic armentarium is responsible for the changing concepts in the treatment of neuropathic detrusor and sphincter dysfunction, and moreover offers the possibility of choice for the same type of neuropathic bladder but with special respects for the individual needs of the patient. It should be stressed that adequate primary care is the prerequisite for successful application of these new treatment strategies and that functional and morphological changes do also occur with these types of therapy, and therefore lifelong urological care is necessary.