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PeripheralNeuropathyandNeurogenicVoidingDysfunctionHann-ChorngKuoDepartmentofUrologyBuddhistTzuChiGeneralHospital
1PeripheralneuropathyCaudaequinasyndromeSacralrootinjuryPelvicplexusinjuryDiabetesneuropathyDetrusordenervation
2Consequencesof peripheralneuropathyDetrusorcontractionsarelostBladderbecomesanacontractilesacBladderemptybyabdominalstrainingorsuprapubiccompression(Credemaneuver)orcatheterizationBladdersensationbecomesvague
3LowerurinarytractsymptomsinPeripheralneuropathyDysuriaStrainingtovoidFrequencyResidualurinesensationUrinaryincontinence(overflow)Urinaryretention
4Physiologyofmicturition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
5CaudaequinalesionLumbarspinalinjurySurgeryforherniateddiscCompleteorincompleteinjurytonerverootsDetrusorcontractilityislostincompletelesionRecoveryofdetrusorcontractilitydependsonseverityoflesion
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8Detrusorareflexiaaftercaudaequinalesion
9Isolatedsphincterobstructionincaudaequinalesions
10Bladderoutletin CaudaequinalesionBladderneckmaybeclosedduetolackofsynchronizedrelaxationduringvolitionalvoidingBenignprostaticenlargementmayincreaseurethralresistanceIsolatedstriatedurethralsphincterresultsinbladderoutletobstruction
11BladderoutletobstructionduetoBPHincaudaequinalesion
12PersistentdysuriaafterTURPincaudaequinalesion
13ChronicLUTDafter CaudaequinalesionBladdercomplianceturnslowerthannormalBladdersensationremainsvagueInisolatedurethralsphincterobstructionthebladderneckisopenandtrabeculatedbladderdevelopsInlowurethralresistance,thebladdermaintainsalowpressurereservoir
14Trabeculatedandpoorcompliantbladderincaudaequinalesions
15Obstructiveuropathyinchroniccaudaequinalesions
16Meningomyelocelewithdetrusorareflexia&closedbladderneck
17Caudaequinalesionwithhighurethralresistance&dysuria
18Caudaequinalesionwithlowurethralresistance,normalflow
19ManagementofNVDafter CaudaequinalesionCleanintermittentselfcatheterizationshouldbeinstructedespeciallyinwomenSuprapubiccystostomymaybeinstitutedinmenUrecholinecanincreaseintravesicalpressureandfacilitatestrainingtovoidAlpha-blockerandstriatedskeletalmusclerelaxant(Baclofenordiazepam)mybehelpful
20SurgicalconsiderationforNVDaftercaudaequinalesionsTransurethralresectionofprostatemaybeperformedinpatientswithanenlargedprostateandincreasedurethralresistanceTransurethralbladderneckincisionforthosewithatightbladderneckIncontinencemaybeacomplicationaftertransurethralsurgery
21SacralrootsinjuryandNVDAfterspinesurgeryortraumaUrodynamicchangesascaudaequinalesionsTransientdetrusorunderactivitywithnormalorabsentbladdersensationLowerurinarytractdysfunctiondependsoncomplexityofnerveinjuries
22PelvicplexusinjuryAlmostalwaystraumaandiatrogenicRadicalsurgeryforcervcalcancerandrectalcancerPelvicfracturewithsevereintrapelvichematoma
23Neuroanatomyofpelvicplexus
24PelvicplexusFormedbytheconfluenceofpelvicparasympatheticnerveswithsympathetichypogastricnervesPelvicplexuscontainsgangliawhereparasympatheticnervesandsympatheticnervesinteractsynchronouslyOnesidepelvicplexusinjurydoesnotinfluencevoidingfunction
25ThePelvicGanglia往橋腦排尿中樞T10-L2髓薦髓S2,3,4逼尿肌核SIN副交感神經節尿道外括約肌
26LocationofpelvicplexusInmen,posteriorplexusliesclosetotheanterolateralwalloflowerrectumandanteriorplexusatposterolateralaspectofprostateandseminalvesiclesInwomen,anteromedialplexusatupperpartofvagina,belowbroadligamentandextendtocardinalligament
27Neuroanatomyofpelvicplexus
28RadicalabdominalhystertectomyDamageofplexuswhenexcisionextendtolevelofcardinalligamentoralongcuffvaginalexcisionUreterliesaboveplexus,avoidureteralinjurywillpreventplexusinjuryLimitedlymphnodedissectioninthesidewithoutcervicalcancerreducespostoperativevoidingproblem
29RectalcancersurgeryPelvicplexusesarevulnerabletoinjuryduringradicalrectalsurgeryPelvicplexusessharethesamefascialsheathwiththelowerrectumPudendalnervemaybedamagedconcomitantlyduringabdominoperinealresectionofrectum(APR)
30NeuroanatomyofPudendalnerves
31Consequencesof pelvicplexusinjuryParasympatheticdecentralizationandleavethegangliaintheplexusordetrusormusclesSympatheticdenervationandlossofcoordinatedregulationwithparasympatheticnervesSensoryafferentnervesinjuryandlossofawarenessofbladderfilling
32Urodynamicchanges afterpelvicplexusinjuryDetrusorareflexiaimmediatelyafterinjuryBladdersensationbecomesvagueandthroughperitoneallayersensationThebladderneckislooseandcanbeopenedbyincreasedintravesicalpressureUrethralsphinctertonemaynotchange
33UrodynamicchangesafterradicalhysterectomyRecoveryofdetrusorcontractilityisusuallyincomplete&takes6-12monthsSignificantresidualurineinthewomenwithlowerabdominalstrainingpressureBladderneckincompetenceandisolatedsphincterobstructionUrethralsphincterEMGactivitymaysynchronouslyincreasedatbladderfilling
34ChangesinbladdercomplianceafterradicalhysterectomyA(n=47)B(n=47)C(n=47)D(n=47)Pvalue<0.05>0.05Residuum(ml)6.61±1.03289.57±24.95*140.83±19.9065.74±11.42A－BA－CA－DB－CB－DC－DRest.P.(cmH2O)12.17±0.7010.91±0.6710.83±0.6518.53±0.76A－DA－BB－DA－CC－DB－CFSF(ml)126.05±6.56249.57±15.15b215.33±15.36c300.51±15.56dA－BB－CA－CA－DB－DC－DCapacity(ml)268.51±11.48334.04±12.81353.33±11.67380.42±17.65A－BB－CA－CC－DA－DB－DCompliance(ml/cmH2O)53.51±6.287.29±0.9613.33±1.6119.17±2.56A－BC－DA－CA－DB－CB－D
35Largecompliantandhypotonicbladderafterradicalhysterectomy
36Detrusorareflexiaandlargebladdercomplianceafterradicalhysterectomy
37Faircompliantandnormotonicbladderafterradicalhysterectomy
38Persistentpoorcompliantbladderafterradicalhysterectomy
39PoorbladdercomplianceafterRadicalhysterectomy
40ChangesinurethralclosurepressureafterradicalhysterectomyMUCP(cmH2O)FPL(cm)A84.14±3.752.96±0.10B60.21±3.202.65±0.10C52.0±1.772.79±0.09D78.08±3.863.09±0.01PvalueA-B,A-C,B-D,C-D<0.05A-D,B-C>0.05A-B,A-C,B-D,C-D<0.05A-D,B-C>0.05
41LowerurinarytractdysfunctionafterradicalhysterectomyDysuriaandstrainingtovoidUrinarystressincontinenceduetolowbladdercomplianceorreducedbladderoutletresistance(bladderneckincompetenceorurethralsphincterinsufficiency)Uppertractdeteriorationinchroniccases
42Isolatedsphincterobstructionafter radicalhysterectomy
43Poorbladdercompliancewithlowurethralresistance
44IncontinenceinPoorbladdercompliancewithrelaxedurethralsphincter
45NormalbladdercompliancewithlowurethralresistanceandSUI
46Complicationsof pelvicplexusinjuryLargeresidualurineFrequenturinarytractinfectionOverflowincontinenceHydronephrosisAzotemiaandrenalscarringEndstagerenalfailure
47UppertractdeteriorationafterRadicalhysterectomyChronicurinaryretentionandpoorbladdercompliancePatientssufferfromincontinence,frequentcystitis,frequentpyelonephritisOccurwhenradiotherapywasperformedinadditiontoradicalhysterectomyAtighturethralsphincterispresent
48ContractedbladderwithBilateralVUreflux
49ManagementofLUTDafterpelvicplexusinjury–DifficulturinationBehaviortherapy–timedvoidingMedication–urecholine,alpha-blocker,striatedmusclerelaxant,nitricoxidedonorsCleanintermittentcatheterizationPeriurethralinjectionofbotulinumtoxin
50BotulinumtoxinAurethralinjectionDysuriaafterradicalhysterectomyresultsfromdetrusorunderactivityandahypertonicurethralstriatedsphincterBotulinumtoxinAexertsaparalyticeffectonstriatedmuscle50to100unitsbotulinumtoxiniseffectiveinreducingsphincterictoneandfacilitatevoidingbyabdominalstraining
51ReducedvoidingpressureafterbotulinumAtoxininjection
52ReductioninMUCPafterBotulinumAtoxininjection
53ManagementofLUTDafterpelvicplexusinjury--IncontinenceBehavioraltherapy–timedvoidingaccordingtourodynamicresultsMedication–methylephedrine,imipramineSurgery–periurethralcollagenorTefloninjectionSurgery–pubovaginalslingprocedureUrinarydiversion–Kockpouch,ilealconduit,ureterostomy,nephrostomy
54ManagementofLUTDafterpelvicplexusinjury–mixeddysuriaandincontinenceUrodynamicevaluationofuppertractdysfunctionIncontinenceshouldnotbetreatedinapoorcompliantbladderCleanintermittentcatheterizationafteranti-incontinencesurgeryisfeasibleWeightheneedofpatientandsideeffectsaftermanagement
55ManagementofLUTDafterpelvicplexusinjury--hydronephrosisBilateralhydronephrosisdevelopinchronicpoorbladdercomplianceCleanintermittentcatheterizationinpatientswithfairbladdercapacityAugmentationcystoplastytotreatpatientswithbothhydronephrosisandincontinenceCISCmaybenecessaryafterbladderaugmentationAvoidsurgeryifCr>2.5orCCr<10ml/min
56Improvedinhydronephrosisafteraugmentationcystoplasty
57LowerurinarytractdysfunctionafterradicalrectalsurgeryUrinaryretention–detrusorareflexiaorunderactivityaftersurgeryUrinaryincontinence–urethralsphincterinsufficiencyduetopudendalnerveinjuryOverflowincontinenceandpoorbladdercompliancearenotcommonfindings
58VideourodynamicstudyafterAbdominoperinealresectionofRectum
59LowerurinarytractdysfunctionafterradicalrectalsurgeryDysuriaandlargeresidualurine–detrusorareflexiaorunderactivityCombinedwithbladderoutletobstructionsuchasBNdysfunctionorbenignprostaticenlargementCystoceleformationafterAPR–lackofposteriorsupport
60TreatmentofdifficulturinationorincontinenceafterAPRDysuriamaybetreatedwithCredemaneuver,intermittentcatheterization,oralpha-blockerIncontinencemaybetreatedwithperiurethralcollagenorTefloninjection,sympathomimeticagentAvoidprostatectomyinpatientswithdetrusorareflexia,incontinencemightbeapostoperativecomplication
