1. Step-by-step Basic Neuro-Urology Teaching
Main voiding dysfunctions of supra spinal lesions
Márcio Augusto Averbeck, MD MSc

2. TOPICS Classification of Supra Spinal Lesions
Patterns of Neurogenic Lower Urinary Tract Dysfunction (NLUTD)
Examples of supra spinal lesions causing NLUTD

3. SUPRA SPINAL LESIONS SUPRAPONTINE PONTINE
CLASSIFICATION
SUPRA SPINAL LESIONS SUPRAPONTINE PONTINE

4. EAU GUIDELINES ON NEURO-UROLOGY (2016)

5. Detrusor Overactivity Coordinated Voiding Voiding right; Timing wrong
Tumors
Encephalitis
CVA
Head injury
Degenerative disease
Parkinsonism
Suprapontine lesion
Detrusor Overactivity
Coordinated Voiding
Voiding right; Timing wrong
Voluntary Sphincter Contraction 5

6. Detrusor Overactivity Detrusor Underactivity Uncoordinated Voiding
Multiple Sclerosis
Multi-System Atrophy
Parkinson’s disease
Tumors
Pontine lesion
Detrusor Overactivity
Detrusor Underactivity
Uncoordinated Voiding
DESD
Involuntary External Sphincter Relaxation 6

7. Cerebral control of micturition
The M and L regions
L Region
M Region
Blok & Holstege, 1997

8. M region => Barrington's micturition centre
It is a small region both specific and necessary to voiding and co-ordination of the bladder and the striated sphincter.
L region => less specific area that probably serves sphincter control in various circumstances, not exclusively micturition.

9. EXAMPLES OF SUPRA-SPINAL LESIONS CAUSING NLUTD

10. Cerebro-Vascular Accidents (CVA) ‚Stroke‘

11. Cerebro-Vascular Accidents (CVA) ‚Stroke‘
One out of 200 inhabitants % above 65 years
Third most frequent cause of death in industrialized countries
20-30 % still suffer incontinence 6 months after CVA, if not treated
Ongoing incontinence is a prognostic sign for poor survival and functional dependance

12. LUT DYSFUNCTION AFTER CVA due to
Cortical lesions
middle cerebral artery
Brain stem lesions
basilar artery
Midbrain lesions
basilar artery (end arteries)
85%
15%

13. LUTS after CVA due to
Cortical lesions
temporo-parietal
frontal
-> control over the bladder becomes defective - cerebral detrusor overactivity

14. LUTS in CVA patients with cortical lesions
N = 72 patients
LUTS at 3 months after stroke => 53%
Nocturia 36 %
Urgency Urinary Incontinence 29 %
Voiding difficulty 25 %
LUTD more common in lesions of the frontal lobe in comparison to the occipital lobe (p<.05).
DO => 68%.

15. Two types of NEW-ONSET UI due to Stroke
Urgency Urinary Incontinence UUI
frontal lesions
Impaired Awareness Urinary Incontinence IA-UI
more parieto-temporal lesions
parietal and temporal lobe responsible for correct identification and perception of signals in certain social situations
Is the strongest predictor of mortality and nursing home residence (OR, 15.1; 95% CI, 3.6–69.7).
Pettersen et al. J Am Geriatr Soc 2007, 55:1571–1577
Incontinent patients not perceiving the urge to void need special behavioural treatments

16. Pons, medulla oblongata
LUTS after stroke
Brain stem lesions
Pons, medulla oblongata
50 % urinary symptoms – more common with haemorrhage
urinary retention 21 %
voiding difficulty 28 %
incontinence 8 %
Urodynamic patterns
Detrusor acontractility in 3/11
Non relaxing sphincter 5/11
Low compliance /11
Detrusor overactivity /11
Uninhibited sphincter
relaxation 3/11
Sakakibara et al. 1996

17. Parkinson’s Disease

18. Parkinson Disease Early diagnosis – non motor symptoms
Disease process begins in the dorsal motor nucleus of the vagal nerve. From there, it takes an essentially upward path through the lower brainstem and basal forebrain until it reaches the cerebral cortex. .
Braak et al., 2005
Early diagnosis – non motor symptoms

19. D1 receptors inhibitory on micturition reflex
D2 receptors facilitate detrusor reflex
LUT dysfunction in PD:
Too little inhibition of D1 or too much facilitation of D2.

20. Parkinson's Disease Causes of Bladder Dysfunction
Urological causes:
prostatic outflow obstruction (men)
cystocele, prolaps, sphincter weakness (women)
Neurological causes:
loss of basal ganglia inhibition detrusor overactivity
bradykinesia of sphincter obstructed outflow
antiparkinsonian drug induced detrusor overactivity

21. Manifested storage symptoms (64%)
J Neurol Neurosurg Psychiatry 2011; 82:
Urinary dysfunction in earlY and untreated Parkinson's Disease
Uchiyama T, Sakakibara R, Yamamoto T, Ito T, Yamaguchi C, Awa Y, Yanagisawa M, Higuchi Y, Sato Y, Ichikawa T, Yamanishi T, Hattori T. Kuwabara S.
Study Design
Diagnosis
50 consecutive untreated PD patients
Mean age: 66,7 ys
Mean disease duration: 23,6 months
Mean Hoehn&Yahr Scale: 1,9
Urinary dysfunction if asked
Manifested storage symptoms (64%)
Subclinical voiding disorders with normal sphincter ani EMG (28%)
Detrusor Overactivity in UDS (82%)
Recent studies reported that a prevalence of urinary symptoms was between 27% and 29%
Urinary symptoms correlated with disease severity being raised to the option that urinary dysfunction in PD is a late stage manifestation.
Patients may have DO in urodynamics without urinary symptoms

22. MULTIPLE SCLEROSIS (MS)

23. MULTIPLE SCLEROSIS (MS)

24. Take-home messages
Suprapontine lesions usually cause detrusor overactivity without DSD.
Pontine lesions may present with a broad range of LUT dysfunctions, including detrusor overactivity, detrusor underactivity, DSD and involuntary sphincter relaxation (depending on the affected area in the pons: M vs L region).

25. THANK YOU !