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  3. Pelvic Organ Dysfunction in Neurological Disease
  • Cited by 8
  • Edited by Clare J. Fowler, The National Hospital for Neurology and Neurosurgery, Queen's Square, London, Jalesh N. Panicker, The National Hospital for Neurology and Neurosurgery, Queen's Square, London, Anton Emmanuel, University College London
Publisher:
Cambridge University Press
Online publication date:
December 2010
Print publication year:
2010
Online ISBN:
9780511762611
DOI:
https://doi.org/10.1017/CBO9780511762611
Subjects:
Neurology and Clinical Neuroscience, Medicine
Information

Book description

Pelvic Organ Dysfunction in Neurological Disease describes the neurological control of human bladder, bowel and sexual function and then details the dysfunctions which may arise as a consequence of various neurological diseases. Easy to read, the book will be of value to any healthcare professional managing patients in whom pelvic organ functions have been compromised by neurological disease. The book provides a structured approach to present day understanding of the neurological control of pelvic organs and the investigation and management of each type of organ dysfunction. A unique feature of this book is that it addresses the impact of specific neurological disorders on all three functions. The authors have all been associated with the Department of Uro-Neurology at the National Hospital for Neurology and Neurosurgery, London since it was established 20 years ago. This book is a timely review of their accumulated knowledge and the latest literature.

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Contents

Page 1 of 2

Contents
  • Chapter 8 - Approach and evaluation of neurogenic bowel dysfunction
    pp 127-137
  • View abstract

    Summary

    Afferent nerve endings in the bladder wall are important in conveying the sensations associated with degrees of bladder fullness and also bladder pain to the spinal cord. This chapter discusses the peripheral control of micturition, cellular signaling pathways in normal bladder function, spinal control of bladder function, and interoceptive sensations. Acetylcholine (ACh) and adenosine triphosphate (ATP) are released by the bladder urothelium during urine storage, in increasing concentrations as the bladder wall distends. Muscarinic, nicotinic and purinergic receptors have been identified in the bladder urothelium and/or suburothelium in human or animal studies. In normal adults information about the bladder is passed from the periaqueductal gray (PAG) to higher regions of the brain. This type of interoception is mediated by afferent input through small-diameter fibers in lamina 1 of the spinal cord. A number of spinal reflex mechanisms are involved in the control of the urethro-vesical unit.
  • Chapeter 10 - Evaluation and management of neurogenic sexual dysfunction
    pp 153-166
  • View abstract

    Summary

    There are a number of neurological diseases which have an effect on bowel function. This chapter provides an overview of gastrointestinal (GI) physiology, with reference to the hindgut and pelvic floor. It addresses the problems caused by common neurological diseases. The intra-abdominal GI tract is varied, and divided into the organs of stomach, small intestine and large intestine. Bowel dysfunction affects approximately 80% of those with spinal cord injury (SCI) and causes more of a problem than urinary and sexual dysfunction in a third of individuals with SCI. Neurological diseases such as SCI or MS frequently impair CNS control of the gut. The difference between the neural control systems for bowel and bladder is underlined by the differing effects of such diseases on the two systems. Supraconal SCI tends to cause difficulty with evacuation of feces in addition to fecal incontinence, but predominantly difficulty with urinary continence.
  • Chapter 11 - Cortical and subcortical disorders
    pp 167-186
  • View abstract

    Summary

    Based on observations under laboratory conditions of over 300 couples, Masters and Johnson identified four discrete phases of the human sexual response as arousal (excitement), plateau, orgasm and satisfaction. This sequence was subsequently modified to include the phase of sexual drive: Kaplan proposed a triphasic response model, each phase with a distinct underlying neurophysiological basis. Libido is defined as the biological need for sexual activity (sex drive) and depends upon hypothalamic and temporal lobe functioning. This chapter outlines the roles of the subcortical and cortical regions, spinal connections and peripheral innervation involved in the phases of the human sexual cycle, with reference to the experimental animal literature and mention of the dysfunctions that can result from neurological disease at each level. Findings from recent functional imaging experiments are discussed in the context of the role of the cortical regions in human neurological control of sexual function.
  • Chapter 12 - Parkinson's disease
    pp 187-205
  • View abstract

    Summary

    Lower urinary tract dysfunction (LUTD) can result from a wide range of neurological conditions. This chapter provides the clinician with an approach to neurogenic bladder dysfunction based on the history, physical examination and investigations, in order to optimize patient management and follow-up. Classification helps with understanding the functional disturbances occurring in neurogenic LUTD. Understanding the underlying dysfunction is paramount before starting treatment. History-taking should address potential dysfunction in both the storage and voiding phases of micturition. Several symptom scales have been validated for the evaluation of urinary disorders, but none are specific for neurogenic LUTD. Physical examination should include neurological, urological, gynecological, abdominal and rectal examination. History, bladder diary and clinical examination may not always be sufficient for understanding the nature of LUTD. Urodynamic tests involve functional and dynamic assessment of the lower urinary tract and are used to assess detrusor and bladder outlet function.
  • Chapter 14 - Multiple sclerosis and other non-compressive myelopathies
    pp 220-240
  • View abstract

    Summary

    This chapter provides an overview of the range of non-pharmacological management strategies available for bladder symptoms and voiding dysfunction that are usually offered by nurses and physiotherapists that specialize in continence. Many patients with neurological bladder dysfunction drink less as their first strategy to reduce their urinary frequency. A continence assessment should precede any proposed management strategy and this is best carried out by a doctor, nurse or physiotherapist who has an understanding of neurological dysfunction and the possible long-term effect on the patient. Patients with voiding dysfunction complain of hesitancy or difficulty in passing urine. The purpose of indwelling catheters is for short- or long-term urinary drainage when alternative methods of urine drainage are unsuitable or no longer appropriate for the patient. Various drainage bags are available for use with an indwelling catheter. Drainage bags are available with a range of fluid volume capacities from 350 to 2000 ml.
  • Chapter 15 - Spinal cord injury
    pp 241-254
  • View abstract

    Summary

    Neurogenic bladder dysfunction has many different pathogeneses and one drug or therapeutic mechanism would be unlikely to be effective for all causes. The human prostate and the bladder neck contain a dense population of a1AR and stimulation of those receptors results in increased smooth muscle tone and increased closure of the urethra. In-vitro studies have shown that non-selective β-adrenoreceptor (βAR) agonists like isoprenaline have a pronounced inhibitory effect on the human bladder, causing increases in bladder capacity. Studies have found that symptoms of sensory urgency are associated with increased TRPV1 expression in the trigonal mucosa. An orally active TRPV1 antagonist has shown the ability to completely prevent bladder reflex overactivity triggered by capsaicin infusion. The TRPV4 cation channel has been found to mediate stretch-evoked Ca2+ influx and ATP release in primary urothelial cell cultures, suggesting this is a sensor molecule in detecting bladder distension.
  • Chapter 16 - Spina bifida and tethered cord syndrome
    pp 255-265
  • View abstract

    Summary

    This chapter describes the different surgical procedures for managing a neurogenic bladder. The procedures include electrical stimulation, bladder and urethral reconstructive surgery, bladder outlet obstruction management and the treatment of stress urinary incontinence. Electrical stimulation to manage bladder dysfunction in patients with neurological disorders has been used since 1950. Electrical stimulation therapies include intravesical electrostimulation, sacral neuromodulation and sacral anterior root stimulation with selective sacral rhizotomy. Cutaneous continent diversions may be performed in neurological patients, mainly in the young myelomeningocele patient or those with spinal cord injury (SCI) who cannot perform clean intermittent self-catheterization (CISC) via the urethra because of congenital abnormalities, urethral pain, obesity, strictures or poor hand mobility. Finally, the chapter describes the suprapubic catheter (SPC), and sphincter surgery, which relieves bladder outlet obstruction due to external urethral sphincter contraction.
  • Chapter 17 - Pelvic organ dysfunction following cauda equina damage
    pp 266-277
  • View abstract

    Summary

    Symptoms of colorectal and anal sphincter dysfunction are common in patients with neurological disorders. The most frequent symptoms of neurogenic bowel dysfunction (NBD) are constipation, fecal incontinence, and abdominal pain. Bowel dysfunction should be viewed in relation to other complications following spinal cord injury (SCI). The international bowel function SCI data sets were developed to collect data on bowel symptoms after SCI in a common format. Most clinicians prefer to support the history with more objective investigations. The technique most often used to study colorectal functions in patients with neurological diseases is radiographically determined colorectal transit time (CTT). Physical evaluation should be performed in all patients. Perianal inspection should be performed to detect pressure sores, hemorrhoids, anal fissures, rectal prolapse or signs of soiling. Anorectal digitations should be performed to assess anorectal sensibility, anal tone and voluntary contraction.
  • 18 - Neuromuscular disorders
    pp 278-292
  • View abstract

    Summary

    Evidence to support management of neurogenic bowel dysfunction remains sparse in comparison to other areas of care; such evidence as is available arises mostly from the spinal cord injury arena. This chapter discusses the clinical and investigational assessment, management of fecal impaction, gastrocolic reflex, abdominal massage, rectal stimulation, and feces evacuation methods. Dysfunction of the bowel has considerable implications for quality of life. Assessment of an individual for neurogenic bowel management is a multidisciplinary activity. Anorectal manometry tests can quantify more precisely the functional status of the anorectum. Irregular or too infrequent management is associated with incontinence and constipation. The majority of individuals with neurogenic bowel dysfunction will use the conservative methods to manage their bowel dysfunction. Biofeedback, Transanal irrigation, surgical interventions, and antegrade continence enema (ACE) are some useful options when conservative methods are not effective.
  • 19 - Urinary retention
    pp 293-306
  • View abstract

    Summary

    Sexual function is recognized as an important factor determining quality of life and dysfunction in neurological patients may significantly add to the burden of their disease. Any disruption in the sexual response cycle results in sexual dysfunction (SD). Laboratory testing should be tailored according to patient symptoms and risk factors. Fasting glucose and lipid profile may be measured to assess atherosclerotic risk factors for erectile dysfunction (ED). Oral drugs should be considered as first-line therapy for neurogenic ED. There are fewer evidence-based therapeutic options for treatment of female SD. However it is an area of increasing interest and marketing of therapies by pharmaceutical companies. Therapies relate to treatment of sexual desire, arousal, orgasm and/or sexual pain. The term hypoactive sexual desire disorder (HSDD) is used to describe low sexual desire and distress, and many therapies aim to address this aspect of female sexual function.
  • Appendix 1: - Management algorithms
    pp 307-311
  • View abstract

    Summary

    This chapter discusses the role of the cortical and subcortical areas in the control of pelvic organs. It presents case histories, the lesion literature, effects of injury or disease at focal sites. The results of diffuse cortical and subcortical diseases are then considered. The temporal lobes have little or no apparent influence on bladder or bowel control but a major role in determining sexual behavior. Cerebrovascular disease is often accompanied by bladder dysfunction. The severity, extent and site of brain damage following brain injury are so variable that generalizations about the effect of traumatic brain injury on pelvic organ dysfunction are impossible. Recommendations have been made to treat specific aspects of sexual dysfunction following traumatic brain injury. An expected correlation is seen between the occurrence of a neurogenic bladder and the severity and extent of brain damage so that urodynamic abnormalities have been associated with motor deficits.

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