1. 排尿障礙治療中心 版權所有 Peripheral Neuropathy and Neurogenic Voiding Dysfunction Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. 排尿障礙治療中心 版權所有 Peripheral neuropathy Cauda equina syndrome Sacral root injury Pelvic plexus injury Diabetes neuropathy Detrusor denervation

3. 排尿障礙治療中心 版權所有 Consequences of peripheral neuropathy Detrusor contractions are lost Bladder becomes an acontractile sac Bladder empty by abdominal straining or suprapubic compression (Crede maneuver) or catheterization Bladder sensation becomes vague

4. 排尿障礙治療中心 版權所有 Lower urinary tract symptoms in Peripheral neuropathy Dysuria Straining to void Frequency Residual urine sensation Urinary incontinence (overflow) Urinary retention

5. 排尿障礙治療中心 版權所有 Physiology of micturition 橋腦排尿中樞 PONS 胸腰髓 T10-L2 薦髓 S2,3,4 骨盆底神經 陰部神經

6. 排尿障礙治療中心 版權所有 Cauda equina lesion Lumbar spinal injury Surgery for herniated disc Complete or incomplete injury to nerve roots Detrusor contractility is lost in complete lesion Recovery of detrusor contractility depends on severity of lesion

7. 排尿障礙治療中心 版權所有 Diagnosis of Cauda equina lesion History of surgical trauma Dysuria and straining to void after spine surgery Constipation is the rule Saddle anesthesia or paresthesia Lower extremity motor deficiency

8. 排尿障礙治療中心 版權所有 Urodynamics of Cauda equina lesion Detrusor areflexia at initial stage, sphincter tone is fixed (normal or weak) Bladder sensation of filling is normal or vague Bladder neck may be closed or open Bladder compliance is normal initially Patients void by abdominal straining

9. 排尿障礙治療中心 版權所有 Detrusor areflexia after cauda equina lesion

10. 排尿障礙治療中心 版權所有 Isolated sphincter obstruction in cauda equina lesions

11. 排尿障礙治療中心 版權所有 Bladder outlet in Cauda equina lesion Bladder neck may be closed due to lack of synchronized relaxation during volitional voiding Benign prostatic enlargement may increase urethral resistance Isolated striated urethral sphincter results in bladder outlet obstruction

12. 排尿障礙治療中心 版權所有 Bladder outlet obstruction due to BPH in cauda equina lesion

13. 排尿障礙治療中心 版權所有 Persistent dysuria after TURP in cauda equina lesion

14. 排尿障礙治療中心 版權所有 Chronic LUTD after Cauda equina lesion Bladder compliance turns lower than normal Bladder sensation remains vague In isolated urethral sphincter obstruction the bladder neck is open and trabeculated bladder develops In low urethral resistance, the bladder maintains a low pressure reservoir

15. 排尿障礙治療中心 版權所有 Trabeculated and poor compliant bladder in cauda equina lesions

16. 排尿障礙治療中心 版權所有 Obstructive uropathy in chronic cauda equina lesions

17. 排尿障礙治療中心 版權所有 Meningomyelocele with detrusor areflexia & closed bladder neck

18. 排尿障礙治療中心 版權所有 Cauda equina lesion with high urethral resistance & dysuria

19. 排尿障礙治療中心 版權所有 Cauda equina lesion with low urethral resistance, normal flow

20. 排尿障礙治療中心 版權所有 Management of NVD after Cauda equina lesion Clean intermittent self catheterization should be instructed especially in women Suprapubic cystostomy may be instituted in men Urecholine can increase intravesical pressure and facilitate straining to void Alpha-blocker and striated skeletal muscle relaxant (Baclofen or diazepam)my be helpful

21. 排尿障礙治療中心 版權所有 Surgical consideration for NVD after cauda equina lesions Transurethral resection of prostate may be performed in patients with an enlarged prostate and increased urethral resistance Transurethral bladder neck incision for those with a tight bladder neck Incontinence may be a complication after transurethral surgery

22. 排尿障礙治療中心 版權所有 Sacral roots injury and NVD After spine surgery or trauma Urodynamic changes as cauda equina lesions Transient detrusor underactivity with normal or absent bladder sensation Lower urinary tract dysfunction depends on complexity of nerve injuries

23. 排尿障礙治療中心 版權所有 Pelvic plexus injury Almost always trauma and iatrogenic Radical surgery for cervcal cancer and rectal cancer Pelvic fracture with severe intrapelvic hematoma

24. 排尿障礙治療中心 版權所有 Neuroanatomy of pelvic plexus

25. 排尿障礙治療中心 版權所有 Pelvic plexus Formed by the confluence of pelvic parasympathetic nerves with sympathetic hypogastric nerves Pelvic plexus contains ganglia where parasympathetic nerves and sympathetic nerves interact synchronously One side pelvic plexus injury does not influence voiding function

26. 排尿障礙治療中心 版權所有 The Pelvic Ganglia 往橋腦排尿中樞 T 10 -L 2 髓 薦髓 S 2,3,4 逼尿肌核 SIN 副交感神經節 尿道外括約肌

27. 排尿障礙治療中心 版權所有 Location of pelvic plexus In men, posterior plexus lies close to the anterolateral wall of lower rectum and anterior plexus at posterolateral aspect of prostate and seminal vesicles In women, anteromedial plexus at upper part of vagina, below broad ligament and extend to cardinal ligament

28. 排尿障礙治療中心 版權所有 Neuroanatomy of pelvic plexus

29. 排尿障礙治療中心 版權所有 Radical abdominal hystertectomy Damage of plexus when excision extend to level of cardinal ligament or a long cuff vaginal excision Ureter lies above plexus, avoid ureteral injury will prevent plexus injury Limited lymph node dissection in the side without cervical cancer reduces postoperative voiding problem

30. 排尿障礙治療中心 版權所有 Rectal cancer surgery Pelvic plexuses are vulnerable to injury during radical rectal surgery Pelvic plexuses share the same fascial sheath with the lower rectum Pudendal nerve may be damaged concomitantly during abdominoperineal resection of rectum (APR)

31. 排尿障礙治療中心 版權所有 Neuroanatomy of Pudendal nerves

32. 排尿障礙治療中心 版權所有 Consequences of pelvic plexus injury Parasympathetic decentralization and leave the ganglia in the plexus or detrusor muscles Sympathetic denervation and loss of coordinated regulation with parasympathetic nerves Sensory afferent nerves injury and loss of awareness of bladder filling

33. 排尿障礙治療中心 版權所有 Urodynamic changes after pelvic plexus injury Detrusor areflexia immediately after injury Bladder sensation becomes vague and through peritoneal layer sensation The bladder neck is loose and can be opened by increased intravesical pressure Urethral sphincter tone may not change

34. 排尿障礙治療中心 版權所有 Urodynamic changes after radical hysterectomy Recovery of detrusor contractility is usually incomplete & takes 6-12 months Significant residual urine in the women with lower abdominal straining pressure Bladder neck incompetence and isolated sphincter obstruction Urethral sphincter EMG activity may synchronously increased at bladder filling

35. 排尿障礙治療中心 版權所有 Changes in bladder compliance after radical hysterectomy A (n=47) B (n=47) C (n=47) D (n=47) P value 0.05 Residuum (ml) 6.61±1.03 289.57±24.95 * 140.83±19.9065.74±11.42 A － B A － C A － D B － C B － D C － D Rest. P. (cm H2O) 12.17±0.7010.91±0.6710.83±0.6518.53±0.76 A － D A － B B － D A － C C － D B － C FSF (ml) 126.05±6.56249.57±15.15 b 215.33±15.36 c 300.51±15.56 d A － B B － C A － C A － D B － D C － D Capacity (ml) 268.51±11.48334.04±12.81353.33±11.67380.42±17.65 A － B B － C A － C C － D A － D B － D Compliance (ml/cm H2O) 53.51±6.287.29±0.9613.33±1.6119.17±2.56 A － B C － D A － C A － D B － C B － D

36. 排尿障礙治療中心 版權所有 Large compliant and hypotonic bladder after radical hysterectomy

37. 排尿障礙治療中心 版權所有 Detrusor areflexia and large bladder compliance after radical hysterectomy

38. 排尿障礙治療中心 版權所有 Fair compliant and normotonic bladder after radical hysterectomy

39. 排尿障礙治療中心 版權所有 Persistent poor compliant bladder after radical hysterectomy

40. 排尿障礙治療中心 版權所有 Poor bladder compliance after Radical hysterectomy

41. 排尿障礙治療中心 版權所有 Changes in urethral closure pressure after radical hysterectomy MUCP (cm H 2 O)FPL (cm) A84.14±3.752.96±0.10 B60.21±3.202.65±0.10 C52.0±1.772.79±0.09 D78.08±3.863.09±0.01 P value A-B,A-C,B-D,C-D<0.05 A-D,B-C >0.05 A-B,A-C,B-D,C-D<0.05 A-D,B-C >0.05

42. 排尿障礙治療中心 版權所有 Lower urinary tract dysfunction after radical hysterectomy Dysuria and straining to void Urinary stress incontinence due to low bladder compliance or reduced bladder outlet resistance ( bladder neck incompetence or urethral sphincter insufficiency) Upper tract deterioration in chronic cases

43. 排尿障礙治療中心 版權所有 Isolated sphincter obstruction after radical hysterectomy

44. 排尿障礙治療中心 版權所有 Poor bladder compliance with low urethral resistance

45. 排尿障礙治療中心 版權所有 Incontinence in Poor bladder compliance with relaxed urethral sphincter

46. 排尿障礙治療中心 版權所有 Normal bladder compliance with low urethral resistance and SUI

47. 排尿障礙治療中心 版權所有 Complications of pelvic plexus injury Large residual urine Frequent urinary tract infection Overflow incontinence Hydronephrosis Azotemia and renal scarring End stage renal failure

48. 排尿障礙治療中心 版權所有 Upper tract deterioration after Radical hysterectomy Chronic urinary retention and poor bladder compliance Patients suffer from incontinence, frequent cystitis, frequent pyelonephritis Occur when radiotherapy was performed in addition to radical hysterectomy A tight urethral sphincter is present

49. 排尿障礙治療中心 版權所有 Contracted bladder with Bilateral VU reflux

50. 排尿障礙治療中心 版權所有 Management of LUTD after pelvic plexus injury – Difficult urination Behavior therapy – timed voiding Medication – urecholine, alpha-blocker, striated muscle relaxant, nitric oxide donors Clean intermittent catheterization Periurethral injection of botulinum toxin

51. 排尿障礙治療中心 版權所有 Botulinum toxin A urethral injection Dysuria after radical hysterectomy results from detrusor underactivity and a hypertonic urethral striated sphincter Botulinum toxin A exerts a paralytic effect on striated muscle 50 to 100 units botulinum toxin is effective in reducing sphincteric tone and facilitate voiding by abdominal straining

52. 排尿障礙治療中心 版權所有 Reduced voiding pressure after botulinum A toxin injection

53. 排尿障礙治療中心 版權所有 Reduction in MUCP after Botulinum A toxin injection

54. 排尿障礙治療中心 版權所有 Management of LUTD after pelvic plexus injury -- Incontinence Behavioral therapy – timed voiding according to urodynamic results Medication – methylephedrine, imipramine Surgery – periurethral collagen or Teflon injection Surgery – pubovaginal sling procedure Urinary diversion – Kock pouch, ileal conduit, ureterostomy, nephrostomy

55. 排尿障礙治療中心 版權所有 Management of LUTD after pelvic plexus injury – mixed dysuria and incontinence Urodynamic evaluation of upper tract dysfunction Incontinence should not be treated in a poor compliant bladder Clean intermittent catheterization after anti-incontinence surgery is feasible Weigh the need of patient and side effects after management

56. 排尿障礙治療中心 版權所有 Management of LUTD after pelvic plexus injury -- hydronephrosis Bilateral hydronephrosis develop in chronic poor bladder compliance Clean intermittent catheterization in patients with fair bladder capacity Augmentation cystoplasty to treat patients with both hydronephrosis and incontinence CISC may be necessary after bladder augmentation Avoid surgery if Cr >2.5 or CCr<10ml/min

57. 排尿障礙治療中心 版權所有 Improved in hydronephrosis after augmentation cystoplasty

58. 排尿障礙治療中心 版權所有 Lower urinary tract dysfunction after radical rectal surgery Urinary retention – detrusor areflexia or underactivity after surgery Urinary incontinence – urethral sphincter insufficiency due to pudendal nerve injury Overflow incontinence and poor bladder compliance are not common findings

59. 排尿障礙治療中心 版權所有 Videourodynamic study after Abdominoperineal resection of Rectum

60. 排尿障礙治療中心 版權所有 Lower urinary tract dysfunction after radical rectal surgery Dysuria and large residual urine – detrusor areflexia or underactivity Combined with bladder outlet obstruction such as BN dysfunction or benign prostatic enlargement Cystocele formation after APR – lack of posterior support

61. 排尿障礙治療中心 版權所有 Treatment of difficult urination or incontinence after APR Dysuria may be treated with Crede maneuver, intermittent catheterization, or alpha-blocker Incontinence may be treated with periurethral collagen or Teflon injection, sympathomimetic agent Avoid prostatectomy in patients with detrusor areflexia, incontinence might be a postoperative complication