1. Buddhist Tzu Chi General Hospital Hualien
Spinal cord injury
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital Hualien

2. Leading causes & Location of Spinal cord injury
Motor vehicle accidents (47%)
Falls (21%)
Sports (14%)
Act of violence (14%)
Location of SCI: cervical (53%), thoracic (35%), lumbar and sacral (10%)

3. Urinary tract symptoms in Acute spinal cord injury
Spinal shock stage: detrusor areflexia, complete anesthesia of fullness or voiding
Recovery of micturition reflex gradually about 1-3 months after recovery of somatic reflexes
Prolonged recovery of voiding reflex may be due to overdistension of the bladder after injury or complication

4. Micturition Control Micturition reflex center – sacral cords S 2-4
Sympathetic nucleus – T10-L1
Micturition control center – pons
Sensory motor center – frontal lobe
Limbic system
Cerebellum, Basal ganglia

5. Pathophysiology of lower urinary tract dysfunction after SCI
Suprasacral cord lesion – interruption of coordination of detrusor contraction and sphincter relaxation
Lesion above T6 SCI – sympathetic hyperactivity during activation of visceral input, bladder distension, rectal distention, cold and noxious stimulation, surgery and infection

6. Chronic spinal cord injury and urinary tract dysfunction
Autonomic dysreflexia – SCI above T5,6 (sympathetic nucleus)
Detrusor external sphincter dyssynergia (DESD) – lesion above S2-4
Detrusor hyperreflexia – complete or incomplete SCI above sacral cords
Detrosor areflexia – sacral cord SCI or cauda equina lesions

7. Urodynamic findings in SCI
Cervical
(n=68)
Thoracic
(n=53)
Sacral or infrasacral
(n=40)
Detrusor hyperreflexia
47(69%)
29 (55%)
2 (5%)
Detrusor areflexia
21(31%)
24 (45%)
38 (95%)
DESD
Presence
41(60%)
20 (38%) -
Absence
27(40%)
33 (62%)
40 (100%) AD
22(32%)
1 (2%)
46(68%)
52 (98%)
DESS=Detrusor external sphincteric dyssynergia; AD=autonomic dysreflexia.

8. Major concern in managing SCI
Preservation of renal function
Free of symptomatic urinary tract infection
Efficient bladder emptying
Freedom of catheter
Continence

9. High risk SCI Patients Complete neurological lesion
Cervical SCI with quadriplegia
Prolonged indwelling catheter
High detrusor leak-point pressure
Presence of DESD and AD
Large residual urine
Presence of vesicoureteral reflux

10. Detrusor leak-point pressure
The intravesical pressure (detrusor pressure) at the end of filling or urinary incontinence
A detrusor LPP of over 40cm water will endanger the upper tract in meningomyelocele
Reduction of detrusor LPP can improve renal function, reduce the risk of UTI, decrease the degree of hydronephrosis, improve vesicoureteral reflux and restore continence

11. Hydronephrosis in SCI
Hydronephrosis is a sign of upper tract deterioration after SCI
In 251 SCI patients, 24 (9.6%) had hydronephrosis, including:
Cervical SCI 7 (5.9% of 118), (3-15) years
Thorac& lumb 8 (8.6% of 93), (3-22)
Sacral (22.5 of 40), (8-26)

12. Autonomic dysreflexia
Spinal cord lesion above T6
Hypertension and increased sympathetic outflow, flushing, sweating above dermatome during increased visceral input (bladder over-distension,urination, rectal distension, surgery, UTI)
Risk of heart failure and stroke
Bladder neck contraction during voiding

13. Cervical SCI autonomic dysreflexia and BN dysfunction

14. Detrusor external sphincter dyssynergia (DESD)
Spinal cord lesion above micturition reflex center
Lack of coordination in the micturition center
External sphincter contrction during detrusor contractions
Dysuria, difficult to initiate voiding, high voiding pressure, large residual urine
Result in frequent UTI and upper tract damage

15. Grades of DESD Grade 0- 3 according to the sphincteric activity
Grade 0 – normal or synergia
Grade 1 – DH &high Pves, hyerreflexic sphincter at initiation, voiding with mild residual urine
Grade 2 – DH or hyporeflexic detrusor, intermittent hyperreflexic sphincter, large residual urine
Grade 3 – DH, closed hyperreflexic sphincter, no spontaneous voiding

16. Grade 1 DESD

17. Grade 2 DESD- High voiding pressure and increased EMG

18. Gr 2 DESD with low voiding pressure and no flow

19. Grade 3 DESD

20. Recovery from spinal shock in Cervical SCI

21. Late Urological Complications in Spinal cord injury
Urinary tract infection induced sepsis
Hydronephrosis and uremia
Stone formation (renal& bladder stone)
Contracted bladder & VU reflux
Incontinence and associated complications
Bladder tumor formation (chronic indwelling catheter)

22. Hydronephrosis in chronic SCI

23. Bladder stones in chronic SCI

24. Vesicoureteral reflux in chronic SCI

25. Analysis of LUTS in 704 SCI
頸髓脊髓損傷
胸髓脊髓損傷
腰髓脊髓損傷
薦髓及以下脊髓損傷 完全
不完全
尿瀦留 14 5 12 3 2
尿失禁（無感覺） 50 18 92 31 13
尿失禁（有感覺） 27 32 24 1
滿溢性尿失禁 8 17 16 11 20
排尿困難 21 4 10
頻尿急尿 9
正常排尿 7
總　　計
122
149
165 72 61
104 26

26. Analysis of UTI in 704 chronic SCI
頸髓脊髓損傷
胸髓脊髓損傷
腰髓脊髓損傷
薦髓及以下脊髓損傷 總計 完全
不完全
從來沒有UTI 31 56 32 21 19 41 4 5
209
(29.7%)
<1 / year UTI 45 46 66 17 22 3
218
(31%)
≧ 1 / year UTI 38 15 57 12 14 1
155
(22%)
不知道 8 10 18 11 24
122
(17.3%)

27. Late complications in 704 SCI
頸髓脊髓損傷
胸髓脊髓損傷
腰髓脊髓損傷
薦髓及以下脊髓損傷 總計 完全
不完全
完全沒有 44 60 43 16 18 3
231
(32.8%)
反覆尿路感染 51 37 78 24 27 22 4
243
(34.5%)
尿路結石 11 10 38 15 5 1 90
(12.8%)
腎臟水腫 6 21 2 8 62
(8.8%)
輸尿管逆流 14 7 19 55
(7.8%)
腎衰竭 25
(3.6%)

28. Management of voiding in 704 SCI in Taiwan
頸髓脊髓損傷
胸髓脊髓損傷
腰髓脊髓損傷
薦髓及以下脊髓損傷 完全
不完全
尿道留置導尿 23 10 14 7 4 2 -
膀胱造廔 13 5 16 1
腹壓排尿 17 39 19 28 11
敲擊腹部 29 24 12
自行反射 27 55 21 3
間歇導尿 6
正常感覺 57 40
其　他
總　計
122
149
165 72 61
104 26

29. The relationship of UTI frequency and SCI level and voiding management
UTI Fequency
0/year
1/year
2/year
3/year
sepsis
Level of SCI
Cervical SCI
41(34.7%)
20 (16.9%)
15 (12.7%)
42 (35.6%) 7
Thoracic or lumbar SCI
17 (18.3%)
21 (22..6%)
38 (40.9%) 4
Sacral or infrasacral SCI
2 (5%)
9 (22.5%)
7 (17.5%)
22 (55%)
Complete lesion 15 30 28 51 9
Incomplete lesion 45 20 11 2
Initial management
Urethral Foley catheter 12 10 16 6
Suprapubic cystostomy 3 14 1
Crede maneuver 13 65
Abdominal tapping,reflex 5 -
CISC
Normal
CISC=Clean intermittent self-catheterization.

30. Considerations in management of LUTD in chronic SCI
Correct complications
Treat hydronephrosis, treat UTI, treat vesicoureteral reflux
Improve quality of life
Treat incontinence, convenience of bladder emptying, free of catheter,free of medication
Individual treatment strategy for each SCI patient

31. Medical Treatment for LUTD in chronic SCI
To reduce detrusor hyperreflexia – anticholinergics (oxybutynin,imipramine)
To reduce bladder neck hyperreflexia – alpha-blocker (tamsulosin, terazosin, prazosin)
To reduce striated sphincter spasticity – skeletal muscle relaxant (baclofen, diazepam)
To increase detrusor muscle tone – cholinergic agent (urecholine)

32. Combination of medication for LUTS in Chronic SCI
To treat incontinence – anticholinergics and adrenergic agnist (methylephedrine) – CISC is needed, residual urine, UTI should be monitored
To facilitate voiding – cholinergic agent and alpha-blocker and skeletal muscle relaxant – incontinence exacerbates, upper tract deterioration if detrusor LPP is high

33. Side effects of Medical Treatment in chronic SCI
Constipation -- anticholinergics
Hypotension –alpha-blocker
Nasal congestion –adrenergic agonist
General weakness – skeletal muscle relaxant
Side effects increase as combination of medication
Cost benefit should be considered

34. Intravesical therapy for SCI
Detrusor hyperreflexia – oxybutynin, capsaicin, resiniferatoxin, botulinum injection
Reversible response
Periodic instillation or injection

35. Capsaicin and resiniferatoxin
Intravesical agents for overactive bladder have been mostly been used in neurogenic bladder disorders
Capsaicin and resiniferatoxin have been successfully used intravesically to reduce urinary incontinence in neurogenic detrusor hyperreflexia
Resiniferatoxin has less acute side effect and similar efficacy as capsaicin
Resiniferatoxin is effective in treating detrusor hyperreflexia refractory to capsaicin treatment

36. Therapeutic effects of resiniferatoxin
10 -5 to M RTX is effective for DH of SCI
10 -8 M RTX can significantly improve voiding pattern and pain score in hypersensitive disorders and bladder pain
RTX is safe for application in humans
Is RTX effective for DESD through inhibition of DH in SCI patients？

37. Successful Therapeutic Effects
Patient became dry
Increase in 50% of maximal cystometric capacity
Subjective improvement rate by >50% in incontinence or dysuria
Significant change in quality of life in urination subjectively

38. Side Effects of RTX Treatment
Autonomic responses
Elevated blood pressure
Headache
Bradycardia
General malaise
RTX was drained out and bladder irrigation was performed if systolic BP >200mmHg

39. Results of resiniferatoxin therapy
20 patients (7 women and 13 men)
Mean age 42.2 ±13.2 (24 – 66) years
10 cervical, 10 thoracic SC lesion
18 traumatic SCI, 2 multiple sclerosis
All had DESD, 9 had autonomic dysreflexia
18 incontinence, 13 dysuria, 8 recurrent UTI

40. Responses of RTX instillation
Initial excitatory response at 1-5 min
Four types of initial responses
Type 1: A sustained high pressure followed by complete detrusor non-contraction Type 2: A high pressure contraction followed by progressively lower amplitude contractions Type 3: Intermittent high pressure contractions Type 4: Intermittent low pressure contractions

41. Initial CMG Tracing after RTX

42. Therapeutic Results of RTX
4/20 became dry during the daytime but incontinent at night time
8/20 had increased in frequency interval and voided volume
8/20 had no significant improvement
8/13 with dysuria had improvement in spontaneous voiding (5) or on Crede maneuver (3)

43. Urodynamic Changes after RTX
Baseline
Post-RTX
Stastistics
Cystometric capacity(ml)
102.1±31.5
236.6±88.6
P<0.001
Bladder compliance
(ml/cmH2O)
23.7±12.1
25.9±15.3
P>0.05
Voiding pressure
(Pdet, cmH2O)
55.9±23.2
47.5±28.1
Presence of
DESD
100%

44. Side Effects and QOL after RTX
Dizziness and headache with high BP and bradycardia (4/20)
Initial gross hematuria (5/20)
Bladder irritation and frequency in all patients
7/20 responded that quality o life improved after RTX
13/20 did not notice any significant change in QOL although objective data showed improved

45. Correlation of RTX Responses with Therapeutic Results
A good response was noted in 12 patients
Type 1: 5 (100%)
Type 2: 4 (80%)
Type 3: 2 (40%)
Type 4: 1 (25%)
Duration of RTX responses: 1 (6m), 6 (3m), 3 (2m), 2 (1m), repeat instillation in 7/12

46. Urodynamic tracings before, during and after resiniferatoxin

47. Botulinum toxin injection
Botlinum toxin has been used to inject striated urethral sphincter for grade 3 DESD
Refractory detrusor hyperreflexia can be eradicated by intra-detrusor injection of botox
Reversible effect and possibilty of antibody formation after repeated injection
Cost-benefit should be weighed

48. Reduction of Voiding pressure after Botulinum toxin in DA

49. Rhythmic detrusor contractions in SCI with DESD after Botox

50. Botulinum A Toxin Detrusor Injection for Detrusor Hyperreflexia
5 IU/Kg Botox (Botulinum A toxin) was injected to 30 sites into detrusor muscle
Decreased detrusor pressure and increased cystometric capacity after Botox
Increased residual urine and CISC is needed
Abdominal tapping to void
Indicated in refractory detrusor hyperreflexia

51. Botulinum A toxin 250 U Detrusor Injection for Detrusor Hyperreflexia

52. Cauda equina lesion and Detrusor areflexia

53. Grade 1 DESD in a SCI Women

54. Grade 1 DESD in Cervical SCI

55. Failure of Pharmacological Mx
Presence of vesicoureteral reflux
Severe bladder fibrosis and trabeculation
Presence of severe bladder outlet obstruction
Severe outlet incompetence
Azotemia or renal failure
No improvement in quality of life

56. Surgical treatment for complications of chronic SCI
External sphincterotomy and urethral stent
Augmentation cystoplasty
Bladder autoaugmentation
Continent urinary reservoir formation (Kock pouch)
Pubovaginal sling procedure
Continent cystostomy
Ureteral reimplantation

57. External Sphincterotomy
Indicated in quadriplegic patients with DESD
Potentially not result in total incontinence
Urinary tract infection can be eliminated
Free of catheterization
Re-do is possible in 25% patients with inadequate sphincter relaxation or scarring
% may have persistent hydronephrosis

58. Technique of Sphincterotomy
12 o’clock position
Incision from BN to bulbous
Cutting deep to fat & vessel
Bleeding can be controlled
Avoid diffused coagulation
On Foley catheter for 2 days

59. Intravesical pressure after external sphincterotomy

60. Reduction in MUCP after External sphincterotomy

61. Urethral Stent
Indwelling a distensible urethral stent for scarred membranous or severe DESD refractory to sphincterotomy
Complication should be weighed: stone formation, stent erosion, persistent UTI, total incontinence
Only 2/11 longer follow-up patients needed to be removed

62. Implantation of a urethral stent

63. Augmentation cystoplasty
A bladder capacity of less than 250ml
Overflow incontinence and large residual urine
Presence of hydronephrosis
Azotemia and frequent pyelonephritis
Patient is able to catheterize by himself
Side effect or refractory to pharmacological therapy

64. Technique of augmentation cystoplasty

65. Surgical results after augmentation cystoplasty

66. Bladder autoaugmentation
Partial myomectomy of bladder wall
Increase bladder compliance and capacity by distensible bladder mucosa
Less surgical morbidity and complication
Secondary fibrosis and reduced capacity after long-term follow-up
Serve as first line surgical procedure for SCI

67. Bladder autoaugmenttion

68. Ureteral reimplantation
Not suitable in trabeculated bladder
High failure rate after ureteral reimplantation or collagen injection
Contraindicated in SCI patients with DESD & AD
Combined augmentation and anti-reflux procedure is a better way

69. Anti-reflux afferent nipple valve

70. Continent Reservoir (Kock pouch)
Creation of a continent reservoir by a 40-cm segment of ileum
Detubularization and double folded ileum can have a volume of 600ml
Anti-reflux and anti-incontinence nipple valves
Self-catheterization is needed
Suitable for female SCI with good hand function

71. Sonography of Kock pouch

72. Degeneration of intestinal wall in Urinary reservoir

73. Transurethral injection
Transurethral injection of botulinum toxin may reduce sphincteric tone and facilitate voiding in SCI with DESD or detrusor areflexia
Transurethral injection of collagen or Teflon paste may bulk sphincter and increase urethral tone, eliminate incontinence in lower level SCI
Other new devices implant into bladder neck or sphincteric urethra to combat incontinence

74. Artificial Urethral Sphincter

75. Artificial Urethral Sphincter
95% in the NVD patients (half of 250) receiving AUS implantation became continent, 78% at the first AUS attempt
Revision rate in neurogenic voiding dysfunction is 33%
Annual incidence of erosion was 5%
Overall success rate was 77%,revision rate 59% in 107 children