THE “ACONTRACTILE” BLADDER - Comtecgroup “ACONTRACTILE” BLADDER - FACT OR FICTION? Jacob Golomb Department of Urology Chaim Sheba Medical Center Tel Hashomer

THE “ACONTRACTILE” BLADDER -

FACT OR FICTION?

Jacob Golomb

Department of Urology

Chaim Sheba Medical Center

Tel Hashomer

NEUROGENIC UNDERACTIVE DETRUSOR

Central (complete/incomplete):

• Spinal cord injury- trauma, vascular, disc disease, spinal stenosis

• Spinal cord disease- myelitis, tumor, MS, spina bifida

• Conus medullaris injury (cauda equina syndrome)

NEUROGENIC UNDERACTIVE DETRUSOR (cont.)

Peripheral- pelvic plexus injury:

• Trauma

• Infection (herpes zoster, Guillain-Barre’ syndrome)

• Pelvic tumor extending to nerves

• Major pelvic ablative surgery (Miles operation, low anterior resection

of rectum, radical hysterectomy)

Diabetic cystopathy:

Decreased bladder sensation Increased capacity

Impaired contractility

• Permanent catheter drainage

• Intermittent catheterization

• Sphincterotomy

Treatment of all entities aims at adequate bladder emptying and

low-pressure storage

TREATMENT OPTIONS FOR NEUROGENIC UNDERACTIVE DETRUSOR

NON-NEUROGENIC UNDERACTIVE DETRUSOR

• DOIC (Detrusor Overactivity with Impaired Contractility)

• Psychogenic urinary retention

• Long-standing bladder outlet obstruction

• Aging

• Idiopathic conditions

“ICS Standard Urodynamic Test: Uroflowmetry and PVR plus

transurethral cystometry and pressure-flow study, all performed in the patient’s

preferred or most usual position; usually comfortably seated and or standing

if physically possible.

The patient(s) may be then reported as having had an ICS standard

urodynamic test (ICS-SUT)’.”.

Peter F.W.M Rosier et al: International Continence Society Standard Good Urodynamic Practices and

Terms 2015. Urodynamics, Uroflowmetry, Cystometry and Pressure-Flow Study.

www.ics.org/Documents/DocumentsDownload.aspx?DocumentID=3077.

Qura

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Vura

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Uroflowmetry#1

4 s 00:24 00:32 00:40 00:48 00:56 01:04

VB MF VE

Qura

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5

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Uroflowmetry#1

20 s 01:20 02:00 02:40 03:20 04:00

VB MF VE

Qura

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5

Vura

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Uroflowmetry#1

15 s 00:00 00:30 01:00 01:30 02:00 02:30 03:00

ST

VB

MF VE

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5

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Uroflowmetry#1

8 s 00:56 01:12 01:28 01:44 02:00 02:16

VB MF VE

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Uroflowmetry#1

4 s 00:44 00:52 01:00 01:08 01:16 01:24 01:32

VB MF VE

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Uroflowmetry#1

4 s 00:28 00:36 00:44 00:52 01:00 01:08 01:16

VB MF VE

Vura

ml0

500

Pdet

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Pves

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Pabd

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EMGave

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Filling & Voiding Cystometry#1

7 s 11:29 11:43 11:57 12:11 12:25 12:39 12:53

CC PI10

VB

PI11 PI12 MF

PI13

PI14

MP

PI15

PI16

VEPI17

Unobstructed

Equivocal

Obstructed

Qura [ml/s]

Pdet [cmH2O]

2 4 6 8 10 12 14 16 18 20 22 24 26

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ICS method p at Void Begin cmH2O30

p at Max Flow cmH2O43

Q at Max Flow ml/s17.8

p at Min Flow cmH2O27

p at End Flow cmH2O27

Desc. Slope cmH2O/ml/s0.9

Flow Delay s0.7

A/G Unobstructed

A/G# 7.6

Qura

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Uroflowmetry#1

6 s 01:24 01:36 01:48 02:00 02:12 02:24

VB MF VE

Vura

ml0

500

Pdet

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Filling & Voiding Cystometry#1

9 s 09:54 10:12 10:30 10:48 11:06 11:24 11:42

CC VB MP MF VE

Unobstructed

Equivocal

Obstructed

Qura [ml/s]

Pdet [cmH2O]

2 4 6 8 10 12 14 16 18 20 22 24 26

20

40

60

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100

120

140

160

180

ICS method p at Void Begin cmH2O83

p at Max Flow cmH2O189

Q at Max Flow ml/s6.9

p at Min Flow cmH2O34

p at End Flow cmH2O17

Desc. Slope cmH2O/ml/s24.3

Flow Delay s0.7

A/G Obstructed

A/G# 175.0

Qura

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5

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Uroflowmetry#1

20 s 01:20 02:00 02:40 03:20 04:00

VB MF VE

Vura

ml0

500

Pdet

cmH2O

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100

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300

Pves

cmH2O

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200

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Pabd

cmH2O

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EMGave

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Filling & Voiding Cystometry#1

15 s 09:52 10:22 10:52 11:22 11:52

CC

PI16

PI17

PI18

PI19

VB

PI20

PI21

MF

PI22

PI23

PI24

PI25

MP

PI26

PI27

PI28

PI29

PI30

PI31

PI32

PI33

PI34

PI35

PI36VE

PI37

Unobstructed

Equivocal

Obstructed

Qura [ml/s]

Pdet [cmH2O]

2 4 6 8 10 12 14 16 18 20 22 24 26

20

40

60

80

100

120

140

160

180

ICS method p at Void Begin cmH2O60

p at Max Flow cmH2O66

Q at Max Flow ml/s8.6

p at Min Flow cmH2O35

p at End Flow cmH2O29

Desc. Slope cmH2O/ml/s3.8

Flow Delay s0.7

A/G Obstructed

A/G# 49.0

Mis-interpretation of urodynamic graphs

• D.A., 66 years old

• 6 months ago AUR

• Following weaning from indwelling catheter he voided only small volumes

• US: trabeculated bladder, prostate 40 gram, PVR 750cc

• Urodynamics:

Started SIC + Betanechol

Repeat Urodynamics

TURP

L.Y., 64 years old

Voiding difficulties for the past 10 years

Was treated with alpha-blockers and betanechol without improvement

On SIC for the past 2 years, no spontaneous voiding

US: trabeculated bladder, prostate 30 grams

Urodynamics:

Advised to

continue SIC

TURP

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Uroflowmetry#1

9 s 00:27 00:45 01:03 01:21 01:39 01:57 02:15

VB MF VE

W,I., 56 years old

Has voiding difficulties for the past 30 years

In 2007 underwent BNI with symptomatic improvement for several years

US: normal bladder, prostate 40 grams

Cystoscopy: interpreted as normal

Urodynamics:

Was started on SIC

TURP

• Detrusor underactivity is defined by the International Continence Society

(ICS) as ‘‘a contraction of reduced strength and/or duration, resulting in

prolonged bladder emptying and/or failure to achieve complete bladder

emptying within a normal time span’’.

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.

• However, the ICS report falls short in specifying parameters for reduced

contraction strength, prolonged bladder emptying, or normal time span.

• Suggested working definition: “The underactive bladder is a symptom

complex, and is usually characterised by prolonged urination time with or

without a sensation of incomplete bladder emptying, usually with hesitancy,

reduced sensation on filling, and a slow stream”.

Chapple CR et al. The Underactive Bladder: A New Clinical Concept?. Eur Urol 68 (2015) 351-353.

Based on a consensus group meeting at the International Consultation on Incontinence–Research Society and ICS

annual meetings in September and October 2014.

IN SUMMARY:

• The urodynamic diagnosis of non-neurogenic detrusor

underactivity in men with LUTS needs to be based on strict criteria,

which are not defined yet.

• Permanent SIC should be applied in men with LUTS and urinary

retention with utmost prudence.

• In non-neurogenic men with urinary retention, the options of

TURP versus permanent SIC should be discussed with the patient.