Basic Evaluation for the MS/SCI Patients  

  • The following findings are commonly seen after the recovery from the spinal shock.

History

  • History and physical examination is extremely important to identify the underlying neurologic conditions and other co-morbidities that can affect lower urinary tract function.
  • Patient history is important in assessing the characteristics and severity of incontinence as well as its impact on quality of life.
  • Loss of normal sensation: A SCI alters the symptoms and signs of illness. Complications may occur without the typical symptoms. [Stover 1991; Miller 1975].
    • Patients with quadriplegia may not feel bladder fullness. In stead, sweating or chill can be presented.
    • Pyelonephritis can occur without flank pain. For more information, please refer to this
    • A ureteral stone without colic
    • An acute abdominal condition without tenderness in the abdomen
  • Conversely, unexpected symptoms or signs, unusual in normal population, may indicate an acute pathologic condition [Colachis 1992; Merritt 1981].
    • An abrupt increase in spasticity: suprasacral lesion
    • Development of AD: suprasacral lesion
  • Patient history alone is not an accurate tool in the diagnosis of sphincteric incontinence, detrusor overactivity or even UTI in SCI/D [Linsenmeyer 2003].

Physical Examination

  • Concept: Physical examination including the followings should be directed to detect anatomic and neurologic abnormalities.
    • Limited general physical examination
    • Complete urologic examination
    • Focused neurologic examination
  • Skeletal muscle tone:
    • Sacral and infrasacral lesion: flaccidity of the lower extremities and anal tone
    • Suprasacral lesions: spasticity of the lower extremities and anal tone
  • Evaluation of dermatomes:
    • Perianal sensation
  • Sacral reflexes: The absence of the following sacral reflexes is highly suggestive of a neurologic lesion involving the conus, cauda equina, or a peripheral nerve. [Norris 1996]
    • Digital anal reflex:
      • Maneuver: examining digit is introduced into the anus.
      • Positive: reflex contraction
      • Pathologic: no or diminished contraction
    • Bulbocarvenous reflex (BCR):
      • Maneuver: sudden squeezing the glans penis or clitoris and feeling (or seeing) the anal sphincter while the examining digit placed in the anus
      • Positive: reflex contraction
      • Pathologic: no or diminished contraction
    • Suprapubic tap reflex:
      • Maneuver: tapping over the suprapubic region may elicit a contraction of the external sphincter around the examining digit in the anus
      • Positive: reflex contraction
      • Pathologic: no or diminished contraction
    • Catheter tug reflex:
      • Maneuver: suddenly pulling the balloon of the Foley catheter against the bladder neck elicits a contraction around the examining digit in the anus.
      • Positive: reflex contraction
      • Pathologic: no or diminished contraction
    • Anocutaneous reflex:
      • Maneuver: light pin-prick in perianal region results in anal ‘wink’
      • Positive: reflex contraction
      • Pathologic: no or diminished contraction
  • Other reflexes:
    • Archilles DTR (L5-S2): should be preserved in sacral lesion
    • Knee jerk reflex (L2-L4): should be preserved in sacral lesion

Laboratory workup

  1. Urinalysis [VIDEO]
  2. Urine Culture: to detect UTI
  3. Renal function test

Urological workup

1. Cystourethroscopy

  • Indications in SCI/D:
    • For the initial diagnostic purpose: controversial
    • Prior to the major reconstructive surgery:
      • Providing anatomical details after anti-incontinence surgery
    • For the long term surveillance: useful
      • Periodic surveillance in patients with augmentation cystoplasty, a long period of indwelling catheterization for potential malignancy
      • To evaluate patients with symptomatic infection for a foreign body, stone or other abnormality.
    • To investigate problems with CIC or IC
    • To evaluate hematuria
  • Points for observation
    • Cystourethroscopic anatomy for male
    • Urethra:
      • Anatomical information on the intrinsic sphincteric deficiency:
        • A fixed and open urethra (pipestem urethra)
        • Luminal infoldings indicating the mucosal seal effect
      • Urethral complications secondary to treatments: Stricture, erosion, false passage, diverticulum
    • Bladder
      • Bladder wall changes (trabeculation)

      • Shape of the ureteral orifices: VUR
      • Any presence of foreign body or bladder stone
  • Clinical significance in SCI/D:
    • Easy quick and useful exam which can be combined with cystometry and cytologic evaluation in long term SCI patients otherwise stable.
    • Long term surveillance
      • Bladder stone, malignancy

2. Uroflowmetry

  • Concept:
    • Measurement of urine flow: flow rate (ml/sec) and flow time
  • Meaning:
    • Total voiding function
    • Detrusor contractility + urethral resistance
  • Parameters:
    • Curve shape: normal = bell shape
    • Qmax (maximal flow rate): normal > 15ml/sec; abnormal <10ml/sec
    • Average flow rate
    • Flow time
    • Time to Qmax
    • Voided volume: should be >150ml for interpretation
  • Clinical interpretation in SCI/D:
    • Not useful in these cases as the study is almost never normal.
    • In an evolving case, for example, after a lumbar disc with retention, a normal flow rate means that voiding function is normal.
  • Clinical significance in SCI/D:
    • A normal flow rate means something but an abnormal flow rate in these cases means little.
3. Measurement of Postvoid Residual (PVR)
  • Definition: the volume of fluid remaining in the bladder immediately after the completion of micturition
  • Measurement technique:
    • Measured by catheterization or ultrasonography
    • Tests should be repeated because the test-retest reliability
  • Interpretation:
    • PVR< 50ml: normal
    • PVR> 200ml: abnormal.
    • PVR between 50ml < < 200ml: requiring clinical correlation
  • Clinical significance in SCI/D:
    • Not very useful in this patient population with the possible exception of quads followed after sphincterotomy. Residual urine is normally about 200 to 300mls more than that suggests a problem.
    • To confirm a bedside leak point pressure -detrusor type with the condom catheter in place. If the Pdet @ leak is more than 20cmH2O there is a problem.

4. CMG, EMG, video UDS

Radiologic Evaluation

  • Being essential to identify the upper urinary tract (kidneys and ureters) status, especially in patients with risk factors. A baseline imaging study is appropriate in all patients with a neurogenic bladder.

1. MRI or CT (spine)

  • Clinical uses:
    • Useful in documenting the level of SCI
    • Expensive and time-consuming imaging technique
  • Clinical significance in SCI/D:
    • Does not correlate with the clinical symptoms or urodynamic findings

2. Ultrasonography

  • Clinical uses: very useful in detecting upper tract abnormality
    • Hydronephrosis
    • Stone (bladder, upper tract)
    • PVR
    • Renal size, bladder wall thickness
  • Clinical significance in SCI/D:
    • Ultrasound is the most useful and noninvasive method of screening tool for detecting above abnormalities
    • Also very useful tool for long-term surveillance of SCI/D

3. Voiding Cystourethrogram

  • Technique:
    • During bladder filling with contrast media, several images are taken in various positions
    • The catheter is then removed and additional images are taken while the patient urinates into a container.
    • Once the bladder is emptied, a final image is taken.
  • Clinical uses: very useful in detecting upper tract abnormality
    • To detect VUR and to grade VUR
    • To delineate anatomy of the bladder (bladder configuration, bladder neck competence) and the urethra during filling and voiding phases
  • Clinical significance in SCI/D:
    • Moderate invasive study
    • VCUG alone is very useful in pediatric population
    • More information can be obtained with combination of simultaneous CMG (video-urodynamic study) than VCUG alone

4. Excretory urography

  • Technique:
    • Radiopaque contrast agent is intravenously injected.
    • Radiographic images are taken at various intervals.
  • Clinical uses:
    • To visualize anatomy of the kidneys, urinary tract, and bladder
  • Clinical significance in SCI/D:
    • Not commonly used for screening
    • May be done to evaluate further specific abnormalities.

5. Nuclear scan (cortical or diuretic renal scan)

  • Technique:
    • Radionuclide is intravenously injected.
    • Images using a camera from multiple projections are taken at various intervals.
  • Clinical uses: may be done to evaluate further specific abnormalities.
    • To assess blood flow to the kidneys and kidney function
    • Renal scarring
  • Clinical significance in SCI/D:
    • Not commonly used for screening
    • May be done to evaluate further specific abnormalities.

Dr McGuire’s Initial Workup for SCI/D

  • I determine the level and extent and nature of the injury. I ask about continence, autonomic dysreflexia, urinary infections, prior treatments, surgery, catheters, urodynamic studies, stones, stone treatment, weight bearing, hand function, bowel and sexual function, method of bladder management, medications, baclofen pumps, home situation, and job history. I look for things that do not seem to fit incontinence in a low thoracic lesion, for example.
  • I do a general physical exam with a focused neurological exam and a genital and rectal exam.
  • With that information we usually would proceed with video urodynamics, a cystoscopy if indicated and some kind of upper tract study.
Key Points of This Section
  • A careful history is most important in this patient population. Some of the conditions you will treat are the result of prior treatments and interventions and you must know what those are.
  • The physical exam is useful to check on the condition of the skin, especially the heels, back buttocks and over the ischial tuberosities, the genitalia and urerthra, the scrotal contents and anal sphincter tone and function
  • The next step is urodynamics to define bladder and urethral function and after that, if required an upper tract study and endoscopy.

References

  • Colachis SC III. Autonomic hyperreflexia with spinal cord injury. J Am Paraplegia Soc 1992;15:171-186.
  • Linsenmeyer TA, Oakley A. Accuracy of individuals with spinal cord injury at predicting urinary tract infections based on their symptoms.J Spinal Cord Med. 2003 Winter;26(4):352-7.
  • Merritt JL. Management of spasticity in spinal cord injury. Mayo Clin Proc 1981;56:614-622.
  • Miller LS, Staas WE Jr, Herbison GJ. Abdominal problems in patients with spinal cord lesions. Arch Phys Med Rehabil 1975;56:405-408.
  • Norris JP, Staskin DR. History, physical examination, and classification of neurogenic voiding dysfunction.Urol Clin North Am. 1996 Aug;23(3):337-43.
  • Stover SL, Lloyd LK, Waites KB, Jackson AB. Neurogenic urinary tract infection. Neurol Clin 1991;9:741-755

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