Committee 10 Neurologic Urinary and Faecal Incontinence Chairman J.J. WYNDAELE (Belgium) Members A. KOVINDHA (Thailand), H. MADERSBACHER (Austria), P. R ADZISZEWSKI (Poland), A. RUFFION (France), B. SCHURCH (Switzerland) Consultants D. CASTRO (Spain), Y. IGAWA (Japan), R. SAKAKIBARA (Japan) Advisor I. PERKASH (USA) 793 ABBREVIATIONS Most abbreviations used in the text are given here, MUP: motor unit potential some in the beginning of the chapter where they are MRI: magnetic resonance imaging used MS: multiple sclerosis Ach: acetylcholine MSA: multiple system atrophy AchE: acethylcholine esterase NBo: neurogenic bowel AD: autonomic dysreflexia NBoD: neurogenic bowel dysfunction ADL: activities of daily living NDO: neurogenic detrusor overactivity ALD: Alzheimer’s disease NLUTD: neurological lower urinary tract dysfunction AS: anal sphincter NUI: neurogenic urinary incontinence AUS: artificial urethral sphincter NVC: natural fill cystometry BCR: bulbocavernosus reflex OR: odd ratio BST: bethanechol supersensitivity test PD: Parkinson’s disease CC: cystometriccapacity PF: pelvic floor CIC: clean intermittent catheterization PFD: pelvic floor dysfunction CMG: cystometrogram PSP: progressive supranuclear palsy CPG: clinical practice guideline Psym: parasympathetic CPT: current perception threshold PVR: post void residual CT: computer tomography QoL: quality of life CTT: colonic transit time RCT: randomised controlled trial CUM: continuous urodynamic monitoring SARS: sacral anterior root stimulation CVA: cerebro vascular accident SCI: spinal cord injury CVC: conventional cystometry SCL: spinal cord lesion DI: double incontinence SDAF: sacral deafferentation DLB: dementia with Lewy bodies SIC: sterile intermittent catheterization DOA: detrusor over activity DRS: digital rectal stimulation SLE : systemic lupus erythematosis DSD: detrusor sphincter dyssynergia SNS: sacral nerve stimulation ES: electrical stimulation SOM: somatic EAS: external anal sphincter SPC: suprapubic catheter EMG: electromyography SSEP: somatosensory evoked potentials EPT: electric perception threshold SSR: sympathetic skin response FI: faecal incontinence SUI: stress urinary incontinence FTD : fronto temporal dementia Sym: sympathetic GBS: Guillain Barre Syndrome TBI: traumatic brain injury ID: indwelling catheter TRI: transrectal irrigation IC: intermittent catheterization TURS: transurethral sphincterotomy IVES: intravesical electrical stimulation UFM: uroflowmetry IWT: ice water test UI: urinary incontinence LBT: lower bowel tract UMN: upper motor neuron LMNL: lower motor neuron lesion US: urethral sphincter LOE: level of evidence USo: ultrasound LS: lumbosacral UTI: urinary tract infection LUT: lower urinary tract UUT: upper urinary tract LUTD: lower urinary tract dysfunction VCUG: voiding cystourethrogram LUTS: lower urinary tract symptoms VSD: vesicosphincteric disorders MPdet: maximum detrusor pressure VSU: vecicoureteral reflux MMC: meningomyelocoele WBC: white blood cells 794 CONTENTS A. INTRODUCTION E. SPECIFIC NEUROLOGIC DISEASES B. PATHOPHYSIOLOGY I. DEMENTIA I. SUPRAPONTINE LESIONS II. MULTIPLE SYSTEM ATROPHY II. SPINAL CORD LESIONS III. PARKINSONS DISEASE III. SUBSACRAL LESIONS (CAUDA IV. CEREBRAL LESIONS AND EQUINA OR PERIPHERAL NERVES) CEREBRO-VASCULAR ACCIDENTS C. NEUROLOGIC URINARY V. MULTIPLE SCLEROSIS INCONTINENCE VI. SPINAL CORD LESION I. EPIDEMIOLOGY VII. SPINAL CANAL STENOSIS II. SPECIFIC DIAGNOSTICS VIII. GUILLAIN-BARRE SYNDROME III. CONSERVATIVE TREATMENT IX. LUMBAR DISC PROLAPSE IV. SURGICAL TREATMENT X. MENINGOMYELOCOELE D. NEUROLOGIC FAECAL INCONTINENCE XI. DIABETES MELLITUS I. EPIDEMIOLOGY XII. PERIPHERAL NEUROPATHY DUE TO IATROGENIC LESION (FOCAL NEUROPATHY) II. SPECIAL DIAGNOSIS OF FAECAL INCONTINENCE IN NEUROPATHIC PATIENTS XIII. SYSTEMIC LUPUS ERYTHEMATOSIS III. CONSERVATIVE TREATMENT XIV. HERPES ZOSTER IV. SURGICAL TREATMENT XV. HIV 795 796 Neurologic Urinary and Faecal Incontinence J.J. WYNDAELE, A. KOVINDHA, H.MADERSBACHER, P. RADZISZEWSKI, A.RUFFION, B.SCHURCH, Y. IGAWA, R.SAKAKIBARA Table 1. Overview of function of the abdominal sympathetic (Sym), the pelvic parasympathetic A. INTRODUCTION (PSym) and somatic (Som) nerves in the LUT and LBT. US= urethral sphincter, AS= anal sphincter. Exp= only suggested in animal experiments, no This chapter deals with all aspects of neurologic clinical evidence. urinary and faecal incontinence. To combine this information related to two different structures makes Sym PSym Som this chapter rather unique though there are sufficient Th 10-L 1 S2-S4 S3-S5 arguments to do so, as presented below. Bladder - + Its content is written from data found in literature with Bladder neck + - the keywords “neurologic”, neurogenic”, “bladder”, “bowel”, “lower urinary tract”, “anorectal”, Extern US exp exp + “incontinence“, “continence”, “urinary”, “faecal”, Bowel + “paralysis”, “dysfunction”, “retention”, “constipation” and the list of the specific neurologic diseases as Intern AS + - described in chapter E. Important information from Extern AS exp exp + the previous ICI report was used as starting point and some is used as such in this chapter, which is intended Pelvic floor + to be able to stand alone. For some topics more elaborate information will be found in other chapters Central control of both continence and evacuation is as on neurophysiology, diagnostics, urodynamic similar and is discussed in the chapter on physiology testing, female, male , frail elderly, faecal incontinence [2]. and more. To look up the related information in these chapters will be worthwhile. Also in chapter E not all Very generally LUT and LBT act quite similar, both are neurologic diseases will be found as we decided in autonomic organs regulated to necessary social consensus to look into the most prevalent or consisting requirements by a somatic innervation. The voluntary of the more challenging in diagnosis and or treatment control depends on accurate sensation [3]. Continence of incontinence. Other colleagues might have made relates to contraction of smooth closing structures a different choice. (bladder neck and internal bowel sphincter) and striated urethral and anal sphincters. An inhibitory It is known that the lower urinary tract (LUT) and the effect on detrusor and lower rectum resulting from lower bowel tract (LBT) are interrelated structures. contraction of the pelvic floor and anal or urethral Embryologically bladder and rectum originate from sphincter has been named a “procontinence” reaction. the same basic structure, the cloaca [1]. Anatomically Micturition and defaecation need a proper relaxation both viscera lay in close communication and share of these latter structures to permit a physiological muscular structures of the pelvic floor. reflex evacuation of urine or faeces. The innervation of both systems depends on Interactions between both functions have been autonomic and somatic nerves (Figure 1) that carry demonstrated. The filling status of the bladder fibres of both. In table 1 a simplified overview is given influences sensation in the rectum and vice versa [4]. of the action linked to different peripheral nerves. A vesico-ano-rectal reflex permits voiding without 797 Figure 1: Schematic overview of innervation of LUT and LBT Figure 2 : Frequent sites of neurologic pathology causing neurologic urinary and faecal incontinence. 798 defaecation [5]. When the bladder is full, sensation of tight thereby retaining stool (Dyssynergia). The rectal filling is decreased. When healthy people visit connections between the spinal cord and the colon the toilet to defaecate, the initiation of micturition often remain intact, permitting reflex coordination and stool precedes that of defaecation, even if both organs are propulsion. This type of lesion provokes faecal considered equally full [6]. The prevalence of both retention at least in part due to the activity of the anal urinary and bowel dysfunction is high in many sphincter. Incontinence can be a consequence of neurological diseases. faecal impaction and constipation. There is no study so far on correlation between both 2. CONUS LESION functions in patients with neurological pathology. If the nuclei of the pelvic nerves are destroyed, the In this chapter levels of evidence (LOE) and grades detrusor becomes areflexic. Retention of urine can of recommendation (A) are used as described in the provoke stress incontinence (formerly termed overflow general introduction of this book. incontinence). III. SUBSACRAL LESIONS (CAUDA B. PATHOPHYSIOLOGY EQUINA OR PERIPHERAL NERVES) The same effect as from lesions of the conus With a neurologic lesion the type of dysfunction that medullaris can result from lesions of the subsacral follows in LUT and LBT will depend on the site, the nerves (cauda equina or peripheral nerves). If the extent and the evolution of the lesion. nuclei of the pudendal nerves are harmed, a paralysis of the urethral sphincter and pelvic floor muscles will Traditionally neurological pathology has been divided occur often with loss of outflow resistance and stress in suprapontine, suprasacral spinal cord and subsacral incontinence. (cauda equina and peripheral nerve) lesions (Figure 2). A neurological lesion affecting the parasympathetic cell bodies in the conus medullaris will eliminate the pelvic I. SUPRAPONTINE LESIONS nerve function of the bowel. No spinal-cord mediated peristalsis will occur. It will be the myenteric plexus that coordinates segmental colonic peristalsis. If the Patients with lesions above the pons usually continue pudendal