The Importance of Urodynamic Study in the Diagnosis of Voiding Dysfunction  

Case 1: A 67-year-old gentleman with a history of T11-T12 SCI managed on CIC

A 67-year-old gentleman with a history of T11-T12 SCI four years ago has been managed on CIC since then. He has complete sensation and catheterizes on urinary urgency. He does not have any incontinent episodes during the day but occasionally leaks at night. He denies any hematuria, flank pain, or urinary tract infection. He has voided a handful of times since his injury.

Videourodynamics [VIDEO] is complicated by spasticity in his left lower extremity, but other than that his bladder fills normally. It is a little trabeculated, but there is a normal capacity with reasonable compliance, a volitional reflex bladder contraction which brings his pressure up to about 50-55cmH2O (marked as * in the cystometry). At this time the bladder neck simply does not open at all. Despite what we originally thought, this is benign prostatic hypertrophy, and bladder outlet obstruction. He had increasing external urethral sphincter pressures throughout filling which is consistent with a normal guarding reflex, and is not typical of a neurogenic bladder where grading reflex responses are delayed. Given this patient's other disease processes, it would be safer to have him a prostatectomy.

After laser prostatectomy, His postvoid residual check on ultrasound is to 60mL which demonstrates adequate bladder emptying. He does have some complaint of urgency. However, his quality of life response suggests that he is happy with his present situation.

Comments and Lessons from This Case: The diagnosis of outlet obstruction by the prostate enlargement is rather complicated in SCI patients since the neurogenic bladder already exists. In this case, it is very difficult to identify the nature and cause of the patient’s voiding dysfunction without urodynamic study. It could be due to the SCI or bladder outlet obstruction. This patient has a transverse myelitis and his findings are atypical nevertheless he was voiding then stopped and developed retention which was attributed to a neurogenic bladder. In fact it was garden variety BPH with a high grade bladder outlet obstruction. Urodynamic testing is essential in these cases as management without the data derived from such studies is quite impossible.

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