Strana 446 VOJNOSANITETSKI PREGLED Vojnosanit Pregl 2014; 71(5): 446–450. UDC: 616.832-004:616.62-008-07 ORIGINAL ARTICLE DOI: 10.2298/VSP120618049B Testing of urodynamic dysfunctions in patients with multiple sclerosis Ispitivanja urodinamskih disfunkcija kod bolesnika sa multiplom sklerozom Rade Baboviü*, Saša Miliüeviü*, Saša Radovanoviü†, Jasna Janþiü‡ *Clinic for Rehabilitation “Dr Miroslav Zotoviü”, Belgrade, Serbia; †Institute for Medical Research, University of Belgrade, Belgrade, Serbia; ‡Clinic of Neurology and Psychiatry for Children and Youth, Faculty of Medicine, University of Belgrade, Belgrade, Serbia Abstract Apstrakt Background/Aim. Multiple sclerosis (MS) is a chronic Uvod/Cilj. Multipla skleroza (MS) je hroniÿno zapaljensko autoimmune inflammatory disorder of the unknown origin autoimuno oboljenje nepoznate etiologije koje dovodi do leading to multifocal demyelization, axonal damage and the multifokalne demijelinizacije, ošteýenja aksona i gubitka ner- loss of the nervous tissue in various parts of the central vnog tkiva u razliÿitim delovima centralnog nervnog sistema. nervous system. Most MS patients have decreased function- Veýina bolesnika sa multiplom sklerozom ima i poremeýenu ality of the bladder leading to various dysuria disorders funkciju mokraýne bešike koja dovodi do razliÿitih dizuriÿnih during the course of the illness. However, in 2% of the smetnji tokom trajanja bolesti. Samo kod 2% bolesnika ove cases dysuric problems are the first symptoms of the dis- smetnje su prvi simptom bolesti. Urodinamsko ispitivanje ease. Urodynamic testing could help to diagnose functional omoguýava nam da postavimo dijagnozu funkcionalnih po- disorders of the lower urinary tract, which might not be remeýaja donjeg urinarnog trakta, što uobiÿajenim invazivnim otherwise possible by performing the standard invasive pro- procedurama ili neinvazivnim snimanjima (ultrazvuk, kom- cedures or noninvasive scans, such us ultrasound, computed pjuterizovana tomografija ili funkcionalna magnetna rezonan- tomography or functional magnetic resonance imaging ca) ÿesto nije moguýe ustanoviti. Metode. Urodinamsko ispi- (fMRI). Methods. Urodynamic testing – cystometry with tivanje – cistometrija i registrovanje elektromiografskih electromyographic (EMG) potentials from the external anal (EMG) potencijala sa spoljašnjeg analnog sfinktera (SAS) sphincter (EAS), was performed in 34 patients (25 female uraĀeno je kod 34 bolesnika (25 žena i 9 muškaraca), koji is- and 9 male patients). Those patients fulfilled Mc Donald’s punjavaju Mc Donaldove dijagnostiÿke kriterijume za multi- multiple sclerosis criteria. The urodynamic values were plu sklerozu. Dobijene vrednosti su uporeĀivane sa neurološ- compared to neurological signs and the present disease kom simptomatologijom i znacima bolesti. Rezultati. Ispiti- symptoms. Results. The MS patients with (27) and without vani su bolesnici sa (n = 27) i bez (n = 7) mikcionih tegoba. (7) miction problems were tested. Detrusor hyperreflexia is Hiperrefleksija detrusor bila je najÿešýi nalaz, prisutan ÿak kod the most common finding, present in 58.8% of the cases. 58,8% bolesnika. Više od polovine ovih bolesnika imalo je More than a half of the patients have detrusor sphincter detrusor-sfinkter disinergiju. Zakljuÿak. Urodinamsko ispiti- dissynergia. Conclusions. Urodynamic testing helps us to vanje može pomoýi da se utvrde postojeýi neurourološki po- determine neurological disorders characteristics and to pre- remeýaji i na osnovu njih planira sprovoĀenje odgovarajuýeg pare an appropriate treatment plan. During the course of terapijskog plana. Tokom trajanja bolesti mogu se ustanoviti the disease different urodynamic disfunctions may occur as razliÿiti oblici urodinamskih nalaza disfunkcije, kao i promena well as changes in the urinating functionality. The rationale funkcije mokrenja. Razlog za sprovoĀenje urodinamskog is- for urodynamic testing in patients suffering from MS before pitivanja kod bolesnika sa MS pre svake terapije bio bi posta- any other treatment procedure is to confirm the diagnosis vljanje jasne dijagnoze dizuriÿnih poremeýaja koja bliže odre- of dysuric disorders and to secure appropriate treatment. Āuje pravilnu i adekvatnu terapiju. Key words: Kljuÿne reÿi: multiple sclerosis; urination disorders; urodynamics; multipla skleroza; mokrenje, poremeýaji; urodinamika; electromyography. elektromiografija. Correspondence to: Baboviý Rade, Clinic for Rehabilitation “Dr Miroslav Zotoviý”, Sokobanjska 13, 11 000 Belgrade, Serbia. Phone: +381 206 2525, +381 64 1301 513. E-mail: [email protected] Volumen 71, Broj 5 VOJNOSANITETSKI PREGLED Strana 447 Introduction urine, urinoculture, blood analysis, sedimentation, and the serum urea, creatinine, uric acid, bilirubin and glucose levels Multiple sclerosis (MS) is a chronic disease of the cen- were determined. tral nervous system (CNS) characterized by the widespread In order to choose adequate functional tests which multifocal lesions in the brain and spinal cord, leading to could enable distinguishing disturbances in urodynamics, visual, sensory, motor and urogenital impairments. The first cystometry was used, combined with description of neuro- attack of the disease usually occurs between the second and genic dysfunction of urination. Measurement gives important third decade of life, affecting working and living activity of data concerning the act of urination – function of the bladder the patients, depending on the severity and the diversity in and preserved sphincter mechanisms 7. the clinical course of the disease 1, 2. Urodynamic studies were performed using a Dantec MS is the disease with extremely varying clinical ex- Logic (Dantec Inc, Copenhagen, Denmark). A double lumen pression, with remissions and exacerbations of different 6–8 F urethral catheter was introduced and normal saline symptoms, usually starting with visual impairments, weak- solution (0.9% sodium chloride) was used at the rate of 10– ness of extremities, diplopia, sensory disturbances and gait 20 mL/min to fill the bladder. Bladder volume, maximum difficulties and disturbances, and urinary and anal sphincter bladder capacity, bladder compliance, vesical (Pves), abdomi- dysfunctions 3. Those dysfunctions comprise of frequent uri- nal (Pabd) and detrusor pressures (Pdet) were monitored si- nating, urgency, incontinency, retention or hesitance. Ac- multaneously during the filling and voiding phases 8–10. Sur- cording to several studies, the incidence of dysuric disorders face electromyography of the external sphincter activity was in MS is 50–97% 3–5. The form of the present dysuric disor- performed. der depends on the size and the position of demyelinated On the basis of urodynamic studies according to Inter- plaques. Therefore, any type and combination of neurogenic national Continence Society standards 7, bladder dysfunction bladder and sphincter dysfunctions is possible during the was classified into 3 groups: detrusor areflexia (DA), defined course of the disease 6. as acontractility caused by abnormality of nervous control, Urodynamic testing is a useful tool in lesion localiza- and detrusor hyporeflexia, defined as detrusor contraction of tion, determination of neurogenic bladder type and might inadequate magnitude and/or duration to effect bladder help to apply the appropriate therapy protocol, based on emptying in a normal time span. The patients with detrusor findings during the disease progression. areflexia and detrusor hyporeflexia were grouped together Urinary disturbances are caused by the lesion of the for analyses due to the small sample size in our study and neural systems controlling the act of miction, and the conse- similar procedure management; detrusor external sphincter quences of these disturbances have to be monitored during dyssynergia (DSD), defined as detrusor contraction concur- rehabilitation of the disease 4. Therefore, the aim of this rent with an involuntary contraction of the urethral and/or study was to choose adequate functional diagnostic tests periurethral striated muscle; detrusor hyperreflexia (DH), de- which could enable us to distinguish the causes of disturbed fined as involuntary detrusor contraction during the filling urodinamics. Performing rehabilitation of MS patients with phase which may be spontaneous or provoked, and cannot be neurogenic dysfunctions of urination enables preservation of completely suppressed due to disturbances of nervous con- the anatomic integrity and functionality of the structures in- trol mechanisms. volved in the act of urination. Depending on the phase of the The presence of urinary infection changes the severity illness, and the type of dysuric disfunctions, proper therapies of the disease symptoms. Therefore, infection must be and procedures should been applied. treated early with the appropriate therapy before urody- namic investigation takes place. At the time of urodynamic Methods investigation, patients were without urinary tract infection and no drugs that influence detrusor and striated sphincter At the Urodynamic Department, Clinic for Rehabilita- behavior. tion “Dr Miroslav Zotoviü”, Belgrade, Serbia, patients with The numerical data are described by mean and their urinary disturbances were tested. The testing protocol com- standard deviations (ʉ± SD), and the categorical data are ex- prises of reviewing patients medical documentation, as well pressed as counts and percentages. The numerical data were as urodynamic testing. A total of 34 patients, 25 female and compared with the