I ORAL PRESENTATIONS

Topic 5: Urinary and Faecal Incontinence (II)
Chair: Jürgen Pannek, Michael Craggs

Introduction Lecture:
URINARY INCONTINENCE IN SPINAL CORD INJURED PATIENTS – NEW
ASPECTS IN TREATMENT
Michael Craggs
Abstract not available

50/5 Modulation of the pundendo-anal reflex with bladder and rectal filling

Balasubramaniam A.V., Chung E.A.L., Bywater H., Middleton F.R.I., Fowler C.,
Emmanuel A.V.,Craggs M.D.
Spinal Research Centre, Spinal Injuries Unit, RNOH NHS Trust, Brockley Hill,
Stanmore, Middlesex, HA7 4LP

Introduction
Supra-sacral spinal cord lesions can cause serious disruption to the
function of the bladder and bowel. Dis-inhibited pelvic reflexes result in malcoordination
of urethral and anal sphincters resulting in an aberrant guarding reflex
(GR) in the bladder1. For the bowel, equivalent overactivity is uncertain. Our aim was to
investigate whether a similar state of aberrance of the guarding reflex exists in these
organs.

Method
Pudendo-anal-reflex (PAR) measurement, using dorsal penile nerve
stimulation, combined with urodynamics and ano-rectal physiology testing measured
the PAR at bladder and rectal end-fill-volumes (PARbefv, PARrefv) which were
normalised to the PAR, recorded with an empty bladder or rectum. Controls and SCI
subjects were compared.

Results
PARbefv responses in cSCI subjects were significantly smaller than controls
(p<0.005). There was no significant difference in the PAR with rectal fill between SCI
and non-SCI individuals.
Conclusions

PAR increase with rectal filling appears to be maintained in SCI.
However the urinary GR appears to be aberrant in its sensitivity to the completeness of
injury.
-0.5
0.0
0.5
1.0
Healthy subjects
iSCI subjects
cSCI subjects
**
n=5 12 8 n=5 4 4
Bladder filling Rectal filling
normalised PARefv
mean ±SD- 1
(standardised to an empty bladder)
PARbefv PARrefv 1 Balasubramaniam AV, Bycroft J, Wood S, Middleton FRI, Fowler CJ,
Craggs MD (2004). Urinary guarding reflex: aberrant in spinal cord injury?
Brit. J. Urol. Int., 93(Suppl 4), 4

51/5 More than a quarter of SCI subjects recover spontaneous micturition.

Ann-Katrin Karlsson, Lena Rutberg, Karin Pettersson, Olof Jonsson, Ingela
Berrum-Svennung
Institution of clinical neuroscience

Spinal cord injury has profound effect on voluntary muscle activity and autonomous
nervous system function, where the loss of voluntary control of urinary outlet is one of
the serious effects that previously caused severe morbidity and mortality. With an
increasing frequency of incomplete injuries the number of SCI subjects who recover
normal micturition increases. In a retrospective chart review of 249 SCI subjects
treated at the SCI Unit, Sahlgrenska University Hospital, Göteborg Sweden we found
that 28 % (n=72) of the sample recovered spontaneous micturition. Level of lesion was
C: 53 % , Th: 18 % and L+S: 29 %. The distribution of level of lesion in the total group
was C 49 %, Th 30 % and L+S: 21 %. The vast majority of the group was ASIA D
(n=51), followed by ASIA grade C (n=11), ASIA E (n=3), ASIA B (n=2) and ASIA A
(n=1) and unclassified (n=4). The female/male distribution was 39/61 % in the group
who recovered spontaneous micturition as compared to 29/71 % in the total group.

When dividing the subjects according to age at injury we found no obvious age
distribution. More than a quarter of SCI subjects recover normal bladder emptying.

52/5 Neuropathic Bladder Dysfunction in Patients with Complete and
Sensory Incomplete Tetraplegia.

Rapidi CA1, Galata A1, Dionyssiotis I1, Salacha M1, Barotsis N1, Micha M1,
Tzavara Ch1, Papadaki P2 and Petropoulou K1
1: 2nd Department of PRM, Neuropathic Bladder Unit, National Rehabilitation Centre,
EIAA, Athens-Greece and
2: Department of Radiology, National Rehabilitation Centre, EIAA, Athens-Greece

Aim: A retrospective study of tetraplegics with complete and sensory incomplete spinal
cord lesion.

Material-Methods: Neurological level of lesion determination according to ASIA
criteria. All patients underwent urodynamics, retrograde cystography and the follow up
period was =18 months.

Fifty three patients were studied: 33 patients with ASIA A and 20 patients with ASIA B.
Forty two men (mean age 31.4y) and 11 women (mean age 38.9y), 51 traumatic and 2
non-traumatic lesions. We studied:

1. The specific type of neuropathic bladder (a:overactive detrusor with
continuous dyssynergia, b:overactive detrusor with intermittent dyssynergia
and incontinence, c:underactive or acontractile detrusor).
2. Reflex volume/Pdet without any anticholinergics
3. Compliance
4. Vesico-ureteric reflux
5. Bladder stones
6. Method of bladder emptying
7. Dose of anticholinergics needed to achieve safe bladder emptying
Fisher exact, Mann-Whitney and student’s t-tests were used for the statistical analysis.

Results: Statistically significant difference was found between ASIA A & B patients
only in (5): p<0.05 and (7): p< 0.001 parameters (see above).

Conclusions: Sensory incomplete lesion of cervical spinal cord seems to play a
protective role in neuropathic bladder dysfunction (less anticholinergics needed, less
bladder stones, less reflux, less Pdet at reflex volume, although the last two were not
statistically significant).

53/5 Tension Free Vaginal Tape (Tvt) Procedure in the Treatment of
Intrinsic Sphincter Deficiency (Isd) in Spinal Cord Injuried (SCI) Patients

G. Del Popolo, A. Macchiarella, M. Celso, G. Lombardi
SOD Neuro-Urologia Spinal Cord Lesions Department Florence ITALY

Objectives: To evaluate efficacy and tolerability of TVT in neuropathic female, mainly
SCI patients, with urinary incontinence due to ISD.

Methods:
From March 1998 to October 2004, we treated 16 women, mean age 53.5, with stress
urinary incontinence (SUI) due to ISD. Follow-up ranged from 3 to 45 months. 11 were
SCI patients, 3 multiple sclerosis, and 2 peripheral neuropathics. 13 used clean
intermittent self-catheterization (CIC) daily. All patients underwent videourodynamic
studies pre and post-TVT. Bladder diaries were checked pre-treatment and during
follow-up. TVT was performed as described by Ulmsten under local anesthesia. Mean
operating time was 28 minutes. The urethral catheter was left post-operatively for 2
days.

Results:
14 of the 16 were completely dry with median follow-up of 20 months. In 1 patient with
spontaneous micturition pre-TVT, the vaginal tape was removed 30 days later due to
complete urine retention. Post-operative urodynamics did not show a significant
modification of maximum urethral closure pressure. All patients in CIC did not refer any
problem concerning catheterism.

Conclusions:
We can affirm, as many Authors reported, that TVT is easy to use, surgery time is
relatively short, and the procedure is free of complications in SCI women using CIC as
well.

54/5 20 Years of Experience with Reconstruction of Bladder Neck
Function in Neurogenic Bladder Dysfunction (NBD) by Use of an Artificial Urinary Sphincter (AUS).

J. Kutzenberger, B. Domurath, D. Sauerwein †
Clinic for Neuro-Urology Werner-Wicker-Hospital, Im Kreuzfeld 4, D 34537 Bad Wildungen

Purpose:
In NBD urinary incontinence takes place often. Video-urodynamic diagnostics are
mandatory for classification of incontinence following NBD. In order to achieve
continence there is necessity to restore the reservoir function of urinary bladder and the
competence of bladder neck as well.

Materials and Methods:
In 1984 to 2004 we implanted an AUS in 125 patients with bladder neck insufficiency
(female 37, male 88). Reasons for NBD were spinal cord leasons (90),
menigomyeloceles (30) and others (5). The reservoir function had previously to be
restored by means of sacral nerve blockade (1), sacral deafferentation (SADF-SARS)
(23), conal deafferentation (2) and ileocystoplasty (2). Implantation of AUS was done
exclusively within 87 cases, but simultanously in combination with other procedures
such as ileocystoplasty (35) and ureteral reimplantation (3), too.

Results:
The follow-up of 100 patients demonstrates continence within 85%. A low UTI-rate of
<1/year, normal compliance (38ml/cmH2O), normal bladder volume (490 ml) and
stable kidney function (74%) are the positive results. Complications such as infections
within ASU-implantation and within ASU with additional surgical procedures, late
infections, different ways of erosion have to be mentioned in detail.

Conclusions:
The indication for AUS in order to restore bladder neck function in NBD is rare.
Restoration of reservoir function is mandatory. There is an increased risk within
combined surgical procedures. Although this circumstance the implantation is well
accepted by the patients, since continence may be achieved within 85%.

55/5 Quality of Life in German speaking Spinal Cord Injury Patients with
Bladder Dysfunction – Assessment of the German Version of the Qualiveen® Questionnaire

J. Pannek, L. M. Schmidt, B. Schurch, R. Märk, M. Stöhrer
Kath. Krankenhaus Marienhospital, 44627 Herne, and the Multicenter Group.

Background: Quality of Life (QoL) may be severely affected in patients with spinal
cord injuries (SCI) and resulting bladder dysfunction. A disease-specific questionnaire
was developed and validated for the first time in French: Qualiveen®. The aim of our
work was to make the 30-item questionnaire available in German and to receive a first
actual status of QoL among a relevant German speaking population.

Methods: The process of translation and cultural adaption was supervised by a QoL
specialist in Germany and a group of physicians from SCI centres in Germany, Austria
and Switzerland.

The final German version of the Qualiveen® questionnaire was completed by more
than 300 SCI patients with bladder dysfunction recruited at 18 clinical SCI centres in
Germany, Austria and Switzerland.

Results: Initial results demonstrated that the German version of the Qualiveen®
questionnaire are equally reliable and valid as the French and English version.
Psychometrical analysis of the first survey will be available at the time of congress.
Interindividual variation of QoL of SCI patients with bladder dysfunction shows variation
and will be presented according to clinical criteria, centre variation and personal
characteristics.

Conclusion: The Qualiveen® questionnaire, the first test instrument for bladderfunction-
related QoL, is available for evaluations with German speaking patients now.
Qualiveen® is a registered trademark of Coloplast A/S, DK-3050 Humlebæk

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