Surgical Treatments

  • Most patients with hyperreflexic dysfunction of the lower urinary tract can be treated using pharmacotherapy, and with or without simultaneous CIC. Only refractory cases are in need of operative reconstruction of the lower urinary tract.
  • The current management of DSD (link to the Tx-3-2-i. General Pharmacological Treatment-Urethra.doc) involves reducing intravesical pressures with antimuscarinic medication, alpha blocking agents and selected tricyclic antidepressants and minimizing intravesical volumes by CIC.
  • This may not be feasible in quadriplegics who lack manual dexterity to do CIC or in patients who do not co-operate with the CIC regimen. In such cases, an indwelling catheter is often used for drainage, but this is associated with of urethral erosion, chronic infection, squamous metaplasia calculus formation, and at 20 years a high cumulative risk for the development of bladder carcinoma.
  • Several operative interventions are available to improve bladder function. The intent is to reduce bladder pressure.  External sphincterotomy can effectively reduce detrusor pressures but can only be used in males. A short term but very similar effect can be achieved by the injection of botulinum toxin into the external sphincter. Or the sphincter can be left alone and the bladder pressure treated by augmentation cystoplasty, sacral dorsal rhizotomy, or botulinum toxin injection into the detrusor muscle. The usual response to medication and CIC, if that treatment is started early is greater than 80%.
  • No true randomized, controlled study of outcomes in patients treated by catheters, or CIC, or other methods exists. What data does exist suggests that serious and indeed devastating complications occur in patients managed by indwelling catheters with much greater frequency than those managed by CIC and bladder pressure control. For example urethral erosion and destruction is invariably related to catheters, as is intractable incontinence. CIC can be associated with clinical problems but only when there is inadequate control of bladder pressure.

References

  • Brindley GS. The first 500 patients with anterior sacral root stimulator implants: general description. Paraplegia 1994; 32: 795-805.
  • Biering-Sorensen F, Nielans HM, Dorflinger T, Sorensen B. Urological situation five years after spinal cord injury. Scand J Urol Nephrol 1999; 33: 157-161.

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