CHAPTER 17 Committee 12 Neurologic Urinary and Faecal Incontinence Chairman J.J. WYNDAELE (BELGIUM) Co Chairs D. CASTRO (SPAIN), H.MADERSBACHER (AUSTRIA) Members E. CHARTIER-KASTLER (FRANCE), Y. IGAWA (JAPAN), A. KOVINDHA (THAILAND), P. R ADZISZEWSKI (POLAND), A.STONE (USA), P. W IESEL (SWITZERLAND) 1059 CONTENTS A.INTRODUCTION E9. GUILLAIN BARRÉ E10. AIDS B. PATHOPHYSIOLOGY E11. LUMBAR DISC PROLAPSE C. NEUROLOGIC URINARY INCONTINENCE E12. CONGENITAL LUMBOSACRAL DEFICITS /MENINGOMYELOCOELE C1. EPIDEMIOLOGY E13. DIABETES MELLITUS C2. SPECIFIC DIAGNOSTICS (+ BOWEL DYSFUNCTION) C3. CONSERVATIVE TREATMENT E14. PERIPHERAL NEUROPATHY DUE C4. SURGICAL TREATMENT TO IATROGENIC LESIONS (FOCAL NEUROPATHY) D. NEUROLOGIC FAECAL INCONTINENCE E15. SYSTEMIC LUPUS ERY THEMATOSUS D1. EPIDEMIOLOGY E16. HERPES ZOSTER D2. SPECIFIC DIAGNOSTICS D3 . CONSERVATIVE TREATMENT F. REFERENCES D4. SURGICAL TREATMENT Abbreviations Most abbreviations used in the text are given here E. SPECIFIC NEUROLOGIC ACE: antegrade continent enema BCR: bulbocavernosus reflex DISEASES AND LUT CC: condom catheter DYSFUNCTION CMG: cystometrogram CUM: continuous urodynamic monitoring E1. DEMENTIA CVC: conventional cystometry DOA: detrisor over activity DSD: detrusor sphincter dyssynergia E2. MULTIPLE SYSTEM ATROPHY EAS: external anal sphincter EMG: electromyography E3. PARKINSON GBS: Guillain Barré Syndrome (+ BOWEL DYSFUNCTION) ID: indwelling catheter IVES: intravesical electrical stimulation E4. ALZHEIMER LBT: lower bowel tract LOE: level of evidence E5. CEREBRAL LESIONS-CEREBRO- LUT: lower urinary tract VASCULAR ACCIDENTS MPdet: maximum detrusor pressure MUP: motor unipotential E6. MULTIPLE SCLEROSIS MS: multiple sclerosis (+ BOWEL DYSFUNCTION) MSA: multiple system atrophy NVC: natural fill cystometry E7. SPINAL CORD LESION PD: Parkinson’s disease (+ BOWEL DYSFUNCTION) PSP: progressive supranuclear palsy PSC: suprapubic catheter E8. SPINAL STENOSIS TURS: transurethral sphincterotomy 1060 Neurologic Urinary and Faecal Incontinence J.J. WYNDAELE, D. CASTRO, H.MADERSBACHER E. CHARTIER-KASTLER, Y. IGAWA, A. KOVINDHA, P. RADZISZEWSKI, A.STONE, P. WIESEL Table 1. Overview of function of the abdominal sympathe- A. INTRODUCTION tic (sym), the pelvic parasympathetic (PSym) and somatic (Som) nerves in the lower urinay tract and lower bowel tract. US= urethral sphincter, AS= anal sphincter. Exp= This chapter deals with all aspects of neurologic uri- only suggested in animal experimentation , no clinical evi- nary and faecal incontinence. dence. It is known that the lower urinary tract (LUT) and the Sym Psym Som lower bowel tract (LBT) are interrelated structures. Embryologically bladder and rectum originate from Bladder - + the same basic structure, the cloaca [1]. Anatomical- Bladder neck + - ly both viscera lay in close communication and share Extern US Exp Exp + muscular structures of the pelvic floor. Bowel + The innervation of both systems depends on autono- Intern AS + - mic and somatic nerves (Figure 1). Extern AS Exp Exp + In table 1 a simplified overview is given of the Pelvic floor + action linked to different peripheral nerves. voluntary control depends on accurate sensation [3]. Continence relates to contraction of smooth closing structures (bladder neck and internal bowel sphinc- ter) and striated urethral and anal sphincters. An inhi- bitory effect on detrusor and lower rectum resulting from contraction of the pelvic floor and anal or ure- thral sphincter has been named a “procontinence” reaction. Micturition and defaecation need a proper relaxation of these latter structures to permit a phy- siological reflex evacuation of urine or faeces. Interactions between both functions have been demonstrated. The filling grade of the bladder Figure 1. Schematic overview of innervation of LUT and influences sensation in the rectum and vice versa [4]. LBT A vesico-ano-rectal reflex permits voiding without defaecation [5]. Central control of both continence and evacuation is similar and is discussed in the chapter on physiology [2]. Very generally LUT and LBT act quite similar: the 1061 B. PATHOPHYSIOLOGY II. SPINAL CORD LESIONS When a neurologic lesion occurs the type of dys- Suprasacral spinal cord lesion When a lesion is function that follows in LUT and LBT will depend located in the spinal cord below the pons detrusor- on the site, the extent and the evolution of the lesion. urethral sphincter dyssynergia is a common finding. Incontinence may still be caused by detrusor overac- Traditionally neurological pathology has been divi- tivity but the outflow obstruction can also cause ded in suprapontine, suprasacral spinal cord and retention. sacral - subsacral (cauda equina and peripheral nerve) lesions (Figure 2). Patients with lesions above the cone usually suffer from an overactive bowel with increased colonic wall and anal tone. The central control of the exter- I. SUPRAPONTINE LESIONS nal anal sphincter is disconnected and the sphincter remains tight thereby retaining stool (dyssynergia). Patients with lesions above the pons usually continue The connections between the spinal cord and the to have reflex contractions of the detrusor. But the colon remain intact, permitting reflex coordination cerebral regulation of voiding and defaecation is and stool propulsion. This type of lesion provokes often lost. This is the case in lesions as from stroke, faecal retention at least in part due to the activity of head injury, etc, which mostly continue to have a the anal sphincter. Incontinence can be a consequen- normal coordinated sphincter function. However ce of faecal impaction and constipation. these patients may purposely increase sphincteric Conus lesion If the nuclei of the pelvic nerves are activity during an overactive detrusor contraction destroyed the detrusor becomes areflexic. Retention [6], to prevent urinary incontinence which would of urine can provoke stress incontinence (formerly otherwise occur. This has been termed “pseudo-dys- termed overflow incontinence). synergia” because it is indistinguishable from true dyssynergia on a urodynamic record. Urinary incon- tinence in suprapontine lesions is due to the bladder overactivity [7]. Figure 2. Frequent sites of neurologic pathology with relation to neurologic urinary and faecal incontinence. 1062 III. SUBSACRAL LESIONS (CAUDA C. NEUROLOGIC URINARY EQUINA OR PERIPHERAL NERVES) INCONTINENCE This part contains all aspects from epidemiology, The same effect as from lesions of the conus medul- pathophysiology, through diagnosis to treatment. laris can result from lesions of the subsacral nerves The ICS Standardization Committee recently intro- (cauda equina or peripheral nerves). If the nuclei of duced a new nomenclature of LUT dysfunctions. the pudendal nerves are lesioned a paralysis of the Terms such as reflex incontinence, detrusor hyperre- urethral sphincter and pelvic floor muscles will occur flexia and overflow incontinence are, according to with loss of outflow resistance and stress incontinen- this nomenclature no longer valid. However in the ce. case of neurologic voiding dysfunction « reflex A neurologic lesion affecting the parasympathetic incontinence » reflects the return of a primitive voi- cell bodies in the conus medullaris will eliminate the ding reflex and, associated with it, incontinence, and pelvic nerve function of the bowel. No spinal-cord therefore this term will still be used here in addition mediated peristalsis occurs. The myenteric plexus to the newly introduced term « neurologic detrusor coordinates segmental colonic peristalsis. If the overactivity » pudendal nerve is also destroyed , there is an increa- Madersbacher et al have described in the ICI report sed risk for incontinence. Apart from the non 2002 common patterns of neurologic detrusor- contractile external anal sphincter, the puborectal sphincter dysfunction in a diagram which is reprodu- muscles also lack tone, which leads to reduction of ced in figure 3. These are easy to use and the deve- the rectal angle. Constipation and incontinence are lopment of similar diagrams for neurologic bowel frequent. dysfunction is to be recommended. While most traumatic spinal cord lesions give LUT and LBT dysfunctions which can be predicted fairly well from the level and completeness of injury [8], C1. EPIDEMIOLOGY the LUT and LBT function in many other neurologic diseases such as meningomyelocoele are more diffi- cult to categorise [9]. Therefore in this chapter a I. METHODOLOGY number of neurologic diseases will be dealt with in detail. Pubmed search from 1967 till 2004 with search words: epidemiology, neurologic bladder, neurologic Figure 3. Patterns of neurogenic detrusor-sphincter dysfunction Heavy lines symbolize hyperreflexia, thin lines hypo- or areflexia and green lines a normal innervation of the relevant structure, for futher explanation see text. 1063 incontinence, neurologic patients, prevalence gave Recommendations several hundreds of references. Unfortunately only a very limited number gave data on prevalence and • Because many diseases or lesions of the only in specific diseases for which a separate search innervation can cause pathology of the LUT, was done. Data on incontinence are not always pre- patients with known neurologic disease sent in data on “neurologic voiding dysfunction” or should be evaluated for such dysfunction . “neurologic cystopathy”. No global meta analysis • Such evaluation should be made not only has been found. when urinary symptoms occur but also as a In separate searches for specific diseases the preva-