NAU-07-0231(20575) Neurourology and Urodynamics 26:1–3 (2008)
PRELIMINARY REPORT
Neurogenic Detrusor Overactivity: Comparison Between Complete and Incomplete Spinal Cord Injury Patients S. Moslavac,1* I. Dzidic,1 and Z. Kejla2
1
Spinal Unit, Special Medical Rehabilitation Hospital Varazdinske Toplice, Varazdinske Toplice, Croatia 2 Department of Spinal Surgery, Traumatology Clinic, Zagreb, Croatia
Aims: To compare leak-point intravesical pressure and cystometric capacity in complete and incomplete spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO). Methods: Retrospective study of filling cystometry at non-physiological filling rate in 80 SCI patients at rehabilitation or annual check-up using Dantec Etude urodynamic machine. Results: Fifty neurologically complete (ASIA (American Spinal Injury Association) (A) and 30 incomplete (ASIA B–E) were diagnosed with neurogenic detrusor overactivity, all with suprasacral level of injury. Mean Pves leak-point pressure (Pves LPP) at cystometric capacity for ASIA A group was 79 30 cmH2O (range 26–140) and mean Pves LPP for ASIA B–E group was 70 29 cmH2O (range 25–130). There was no significant difference between groups (P ¼ 0.234). Mean CC (cystometric capacity) for ASIA A group was 239 107 ml (range 47–526) and mean CC for ASIA B–E group was 227 125 ml (range 42–500). Again, no significant difference was found (P ¼ 0.655). Conclusions: No difference in cystometric capacity and intravesical leak point pressure at terminal detrusor overactivity was shown between complete and incomplete spinal cord injury patients in our survey, that is, represented findings are equally unfavorable for both groups. Incomplete SCI patients with NDO should be tested with cystometry and observed with same caution as we proceed in complete SCI patients. Neurourol. Urodynam. 9999:1–3, 2008. ß 2008 Wiley-Liss, Inc. Key words: cystometry; detrusor overactivity; incomplete spinal injury
INTRODUCTION
Neurogenic detrusor overactivity (NDO) is a common consequence of suprasacral spinal cord injury (SCI) along with loss of motor and sensory functions below the injury level. If not properly treated and monitored during rehabilitation and throughout lifetime, NDO may lead to a number of potential life-threatening complications such as urinary tract infections, vesico-ureteral reflux, hydronephrosis and pyonephrosis, especially when accompanied with detrusorsphincter dyssinergia. Along with morphologic changes seen on renal and bladder ultrasound scan, urodynamic filling cistometry is done to monitor pressure–volume relation in the bladder, where values of leak point intravesical pressure and cystometric bladder capacity represent important findings in validating the risk of upper urinary tract damage. Completeness of neurological injury is graded according to American Spinal Injury Association (ASIA) impairment scale.1 Clinician might presume that incomplete (ASIA B–E), even ambulatory (ASIA D–E) SCI patients will naturally have more beneficial intravesical pressure and bladder capacity than complete (ASIA A—totally paralyzed and anesthetic) patients, and omit urodynamics. However, it has been demonstrated that even neurologically intact patients with thoracolumbar cord injuries may have lower urinary tract dysfunction on urodynamics.2 Furthermore, Patki et al.3 concluded that incomplete SCI have neuropathic bladder
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unless proved otherwise and that salient deterioration in bladder dysfunction is not uncommon. Therefore filling cystometry is routinely performed in all SCI patients in order to define bladder capacity and intravesical pressure, thus setting up the bladder management program. The objective was to compare these values in complete and incomplete SCI patients with neurogenic detrusor overactivity. Our hypothesis was that two groups of patients do not differ in leak point intravesical pressures and cystometric bladder capacities, which, if demonstrated, represent equally unfavorable findings of neurogenic bladder in incomplete, as are in complete SCI patients. MATERIALS AND METHODS
This is a retrospective study in a 2-year period from October 2004 to September 2006, with spinal cord injury patients undergoing water filling cystometry during rehabilitation *Correspondence to: S. Moslavac, M.D., Spinal Unit, Special Medical Rehabilitation Hospital, 42223 Varazdinske Toplice, Croatia. E-mail:
[email protected] Received 2 December 2007; Accepted 18 January 2008 Published online in Wiley InterScience (www.interscience.wiley.com) DOI 10.1002/nau.20301
2
Moslavac et al.
or annual check-up in Spinal Unit of the Special Medical Rehabilitation Hospital Varazdinske Toplice, Croatia. Their neurological injury was stable and they were all out of spinal shock. Completeness of injury according to ASIA impairment scale1 was noted, where ‘‘A’’ represents complete injury with total motor and sensory loss below the injury level, while ‘‘B’’–‘‘E’’ stand for incomplete injury with preservation of peri-anal sensation (‘‘B’’) or residual motor (‘‘C’’, ‘‘D’’, ‘‘E’’) function, with ‘‘D’’ and ‘‘E’’ representing useful motor function with ambulatory capability. Filling cystometry is the method by which the pressure/ volume relationship of the bladder is measured during bladder filling. Procedure was performed with Dantec Etude urodynamic machine at non-physiological filling rate. A doublelumen 8F catheter was inserted transurethrally into the bladder. Cystometric capacity (CC) and leak point intravesical pressure (Pves LPP) at terminal detrusor overactivity (a single, involuntary detrusor contraction, occurring at cystometric capacity, which cannot be suppressed and results in incontinence) were recorded. Cystometry was stopped at the onset of incontinence and in six patients (five with ASIA A and one with ASIA B) it was accompanied with the symptoms of autonomic dysreflexia. The urodynamic evaluations conformed to the International Continence Society standardisation.4 Only patients with urodynamic findings consistent with neurogenic detrusor overactivity (involuntary detrusor contractions during the filling phase) were included in the study. Two groups of NDO patients were formed: complete (ASIA A) and incomplete (ASIA B–E) patients. All patients agreed with the procedure as routine clinical investigation, and the study was approved by the local ethical committee. Independent sample t-tests for equality of means were used to determine if differences existed between the groups. For all analysis, significance was established when P < 0.05. Descriptive statistics was used and data are presented as means standard deviation. Distribution was tested with Kolmogorov–Smirnov test. All statistical analysis were performed using SPSS for Windows, version 13.0. RESULTS
Fifty neurologically complete SCI patients (ASIA A) and 30 incomplete (ASIA B–E) were diagnosed with neurogenic detrusor overactivity, all of them with suprasacral level of injury. Mean Pves LPP at cystometric capacity for ASIA A group was 79 30 cmH2O (range 26–140) and mean Pves LPP for ASIA B-E group was 70 29 cmH2O (range 25–130). A two-tailed t-test for equality of means was 1.2, df ¼ 78, P ¼ 0.234, which was not significant (Fig. 1). Mean CC for ASIA A group was 239 107 ml (range 47–526) and mean CC for ASIA B–E group was 227 125 ml (range 42–500). A twotailed t-test for equality of means was 0.448, df ¼ 78, P ¼ 0.655, which was not significant (Fig. 2). Despite data dispersion, distribution remained normal.
Fig. 1. Intravesical leak-point pressures (Pves LPP) in complete (ASIA A) and incomplete (ASIA B–E) spinal cord injury patients.
showed large variability in both groups, indicating high risk patients with extreme findings in both groups, with potential to develop upper urinary tract damage in those that have lower bladder capacity and higher intravesical pressure. Mean cystometric capacity in both groups (239 and 227, respectively) represent reduction by half of normal values, which clinically denotes frequent urination or need for increased number of intermittent catheterization a day. Similarly, means for Pves LPP in both groups (79 and 70 cmH2O, respectively) are higher than in able-bodied population, since a value of 40 cmH2O is proposed as cut-off value between intravesical low-pressure and high-pressure.5 Such pressures might lead to vesicoureteral reflux, especially if detrusorsphincter dyssinergia accompanies NDO, and bladder management program in both SCI groups must be carefully set and revised according to urodynamic findings throughout lifetime, in majority of cases intermittent catheterization with anticholinergic medication being the safest treatment. We remain with null hypothesis claiming no difference between these two groups with respect to investigated variables, which is clinically particularly relevant for the incomplete SCI patients as they might be taken less seriously
DISCUSSION
No differences in cystometric bladder capacities and leak point intravesical pressures at terminal detrusor overactivity were demonstrated between complete and incomplete spinal cord injury patients in our survey, that is, represented findings are equally unfavorable for both groups. This is more important for incomplete patients as clinicians might fail to recognize the severity of neurogenic detrusor overactivity, especially in ambulatory patients (ASIA D and ASIA E), as was reported previously.2,3 Both monitored values (Pves and CC) Neurourology and Urodynamics DOI 10.1002/nau
Fig. 2. Cystometric bladder capacities (CC) in complete (ASIA A) and incomplete (ASIA B–E) spinal cord injury patients.
Neurogenic Detrusor Overactivity in Complete and Incomplete SCI PatientsQ1 than complete when their symptoms of neuropathic bladder is observed. CONCLUSION
Incomplete SCI patients with NDO should be tested with cystometry and observed with same caution as we proceed in complete SCI patients. REFERENCES 1. Maynard FM, Jr., Bracken MB, Creasey G, et al. International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Injury Association. Spinal Cord 1997;35:266–74.
Q1: As per the journal style maximum limit of 45 characters (including space) is allowed for short title. Please reduce the short title accordingly.
Neurourology and Urodynamics DOI 10.1002/nau
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2. Watanabe T, Vaccaro AR, Kumon H, et al. High incidence of occult neurogenic bladder dysfunction in neurologically intact patients with thoracolumbar spinal injuries. J Urol 1988;159:965–8. 3. Patki P, Woodhouse J, Hamid R, et al. Lower urinary tract dysfunction in ambulatory patients with incomplete spinal cord injury. J Urol 2006;175: 1784–7. 4. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167– 78. 5. McGuire EJ, Cespedes RD, O’Connell HE. Leak-point pressures. Urol Clin North Am 1996;23:253–62.
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