II POSTER PRESENTATIONS

Topic 4: Neurogenic Detrusor Overactivity

30 Modification of Urodynamic Parameters in Neurogenic Bladder of
Spinal Cord Injured Patients Treated with Intrathecal Baclofen Infusion

P. Salucci, I. Baroncini, A. Costa, C. Mancusi, G. Bazzocchi, P. Pillastrini,
M. Menarini
Spinal Cord Unit - Montecatone Rehabilitation Institute - Imola (Bologna) - Italy

We considered a group of 32 patients (20 paraplegic, 12 tetraplegic), who received
from 1995 to 2003 an implant for intrathecal Baclofen infusion. All the patients had
urodynamic test before and 6-8 months after the implant.

The achieved values have been tested by statistical analysis one-way ANOVA, with
Dunnett’s multiple comparison test.

The data analysis has shown an increase of bladder capacity in 59% of patients, either
for paraplegic or for tetraplegic ones (before 231 ± 107 ml, after 303 ± 119, p<0,05).
Maximal detrusor pressure decreased in 58% of tetraplegic patients and in 34% of
paraplegic ones (before 80 cm H2O ± 55, after 74 cm H2O ± 37, p>0,05).
As far as the maximal urethral pressure is concerned, we noticed a reduction in 56% of
patients (before 101 cm H2O ± 48, after 94 cm H2O ± 44, p>0,05).
The detrusor striated-sphincter dyssynergy disappeared after implant in 38% of cases,
while it remained stable in 58% of patients and worsened in 3% of cases.
The analysis of this sample of SCI patients has shown a moderate improvement of
urodynamic parameters. Baclofen could most likely act as bladder overactivity inhibitor.

31 Delayed return of reflex activity in autonomic nervous system –
remaining spinal shock in the bladder 3-4 month post injury

Ann-Katrin Karlsson, Karin Pettersson, Ingela Berrum-Svennung, Olof Jonsson
Instit of clinical neuroscience Sahlgrenska Academy, Göteborg, Sweden

In the acute stage of spinal cord injury most subjects suffer from a flaccid paresis, low
muscle tone, absence of tendon reflexes and a flaccid bladder the so called spinal
shock. Approximately 2-5 weeks post injury the muscle tonus increases and tendon
reflexes return. However it seems as the return of reflex activity in the autonomic
nervous system (ANS) activity might show another time course.

In a retrospective chart review of 147 SCI individuals treated at the SCI Unit at
Sahlgrenska University Hospital who was investigated by cystometry we evaluated the
frequency of spinal shock in the material. Spinal shock was defined as absence of
reaction at Bohr´s ice water test and no increase in intravesical pressure during filling.
Cystometry was done 3-4 months post injury.

We found that 14 % (n=20) of the investigations still showed spinal shock 3-4 month
post injury. In a follow up 1-3 years later 14 was characterised as upper motor neurone
lesion, 4 were classified as lower motor neurone lesion and 2 were lost for follow-up.
The return of reflex activity in the ANS system seems to follow another time course
than the reflex activity in the somatic nervous system.

32 The frequency of bacteriuria and urinary tract infection in 249 spinal
cord injured.

Karin Pettersson1, Olof Jonsson1, Ingela Berrum-Svennung1, Peter Asplund2,
Ann-Katrin Karlsson1
Instit of Clinical Neuroscience

The occurrence of resistant bacterias is increasing. At our SCI Unit in Göteborg,
Sweden urinary cultures are performed on all patients twice weekly. In a retrospective
chart review of 249 SCI patients we investigated the frequency of bacteriuria, bacterial
species and treatment related to emptying regime, age and sex. 7.812 urinary cultures
were evaluated.

38 % of the cultures showed bacteriuria, (C:41 %, Th:38 %, L+S:33%). The age and
sex distribution was equal. 30 % of the positive cultures were treated with an equal
distribution according to level of lesion, sex and age. Bacteriuria was found in 33 % of
the subjects who recovered normal micturition, 37 % of the CIC, 40 % in the mixed
regime and 55 % of the CAD group. The bacteriuria was treated in 24 % of the normal,
32 % of the CIC , 34 % in the mixed and 25 % of the CAD group. The most common
bacterial species were enterococcus (29 %) Klebsiella (23 %) and E.Coli (18 %).
MRSA was found in 1,5 % of the cultures. By regular culturing of urine we could treat
according to pattern of resistance and the creation of resistant bacterias might be
avoided.

33 Bladder-filling sensation in patients with complete spinal cord injury

Ji Cheol Shin, Chang Il Park, Eun Joo Kim , Jee Hyun Yoo
Department of Rehabilitation Medicine and Research Institute of Rehabilitation
Medicine, Yonsei University College of Medicine, Seoul, Korea

The aims of this study were to classify complete SCI patients based on the
preservation of bladder-filling sensation and to investigate the potential for sensationdependent
bladder emptying.

This study was performed retrospectively on 118 complete SCI patients with lesions
above T11 who were referred to the urodynamic laboratory. Patients were classified
according to the preservation of bladder-filling sensation (especially first voiding desire)
during the conventional urodynamic study. Patients with first voiding desire were
classified again according to the presence of first voiding desire in detrusor pressure
(Pdet) lower than 40 cmH2O, and the simultaneous presence of maximum bladder
capacity (MBC) of more than 350 ml. And the mean volume of first voiding desire
volume and the ratio between first voiding desire volume and MBC were calculated.
There were 32.2% with preservation of first voiding desire. 68.4% of these patients had
first voiding desire before Pdet reached 40 cmH2O and the simultaneous MBC was
more than 350 ml. However, their mean volume of first voiding desire volume was
277.35 ml and the ratio between first voiding desire volume and MBC was 59.15%.
Therefore, sensation-dependent bladder emptying method may induce premature
bladder emptying and may result in contracted bladder.

34 Effect of Anticholinergic Treatment on Neurogenic Bladder Function
in Spinal Cord Injured Patients

Gunduz B, Erhan B, Lakce E, Akyurek B, Elbasi N
70. Yil Istanbul PMR Training Hospital, Istanbul, Turkey

Aim: The aim of this study was to evaluate the effects and tolerability of anticholinergic
treatment with clinical features and urodynamic parameters in patients with detrusor
overactivity due to spinal cord injury.

Methods: Spinal cord injured patients diagnosed as detrusor overactivity and taking
anticholinergic treatment were reevaluated with video urodynamic study during follow
up visits. The records about urine leakage were assesed. The patients who did not
used the prescribed drug were taken as the control group.

Results: Thirty five patients with spinal cord injury were included in the study. Twenty
one had been using anticholinergic treatment for a mean duration of 17 months; 14
patients were taken as the control group. Both groups were similar in demographic
characteristics and pretreatment urodinamic parameters. The cystometric bladder
capacity increased and detrusor leak point pressure decreased significantly in the
anticholinergic drug group. Both parameters decreased insignificantly in the control
group. All the patients in the anticholinergic drug group reported an improvement in the
leakage of urine; fifty percent of them did not have incontinence episodes any more.
Conclusion: Anticholinergic treatment has favorable effects both in the urodynamic
parameters and clinical symptoms of the spinal cord injured patients with detrusor
overactivity.

35 The Long-Term Neurourological Management of Spinal Cord Injured Patients

Erhan B, Gunduz B, Baran S, Coskun E, Basar G
70. Yil Istanbul PMR Training Hospital, Istanbul, Turkey

Aim: The aim of this study was to evaluate the neurourological status of spinal cord
injured patients attending the follow-up clinic of a rehabilitation center during 2002-
2004.

Material and Methods: One hundred ninety one spinal cord injured patients were
examined and classified according to ASIA/IMSOP standarts. Biochemical tests, urine
analysis and urinary ultrasonograghy were recorded. The patients were investigated for
the method of bladder management and drug consumption.

Results: The mean age was 34.86±14.58 years. The mean duration of injury was
58.9±51.1 months. According to ASIA classification 49.7% of the patients were
complete, 51.3% were incomplete; 65% of the patients were at or above T11, 20.4%
between T12 and L1, 14.6% below T12. The bladder management methods were clean
intermittant catheterization in 52%, spontan voiding in 30% , indwelling catheterization
7% and other methods in the rest. Forty two percent of the patients were on
anticholinergic drugs.

Conclusion: The urological complications are common among spinal cord injured
patients. The appropriate urological management and follow up are the only way to
prevent these complications. In this study we conclude that most of our follow-up
spinal cord injured patients obey the ordered management protocol and use ideal way
for emptying bladder.

36 Botulinum-toxin-A management of compensated renal failure –
detrusor hyperreflexia in a myelomeningocele (MMC) children

Hagen Loertzer , Sigrid Wagner, Paolo Fornara
University Clinic and Policlinic for Urology of the Martin-Luther-University Halle,
Germany
Director of the clinic: Univ. Prof. Dr. P. Fornara

Introduction:
The treatment with botulinum-toxin A of detrusor hyperreflexia in myelomeningocele
(MMC) chlidren is an effective and safe therapy. A 17year old girl with a detrusor
hyperreflxia in MMC was admitted to hospital with compensated renal failure (creatine:
204µmol/l, urea 11,2 µmol/l, cystatin C 2,07mg/l), urinary tract infektion 2 times per
months. She performed clean intermittent catherisation (CIC) due to MMC,
incontinence score 3. We could verify a vesico-renal reflux IV°.

Method:
We injected 300 U botulinum-toxin A (Botox®) at 30 sites of the detrusor. 6 mounths
after the first intravesical injection we repeated the therapy with 1000 U botulinum-toxin
A (Dysport®) at 30 sites of the detrusor. The third injection was also 6 mouths later and
we injected 1000 U botulium-toxin A (Dysport®).

Result:
She improved from incontinence score 3 to 1, reduced panty liner of 6 to 1 per day.
Renal function improved: crea: 110 µmol/l, urea 5,6 µmol/l cystatin C: 1,12mg/l. The
vesico-renal reflux IV° decreased to vesico-renal-reflux II°. The urinary tract infection
rate was reduced to 1 time in 6 months.

Conclusion:
Preliminary result is pormises a good treatment option in the managment of detrusor
hyperreflexia in MMC children with a vesico-renal-reflux and compensated renal failure.

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