Detrusor Internal Sphincter Dyssynergy: an underappreciated source of neurogenic bladder dysfunction in children with Cerebral Palsy.
Andrew J. Combs, PA-C, Jason Van Batavia, MD, Kenneth I. Glassberg, MD.
Columbia University Medical Center, New York, NY, USA.
Background: The most common clinical urologic manifestations reported in patients with cerebral palsy (CP) are urinary incontinence, enuresis,frequency and urgency and to a lesser degree, urinary tract infections and urinary retention. Reports in the literature on the urodynamic findings in these children are sparse and when noted, report incidences of neurogenic detrusor overactivity (NDO)as high as 80% and associated external urethral sphincter dyssynergia (DESD)in upwards of 40%. None to date have reported on there being any associated bladder neck/internal sphincter dyssynergy (DISD) likely reflecting that most children when studied urodynamically are evaluated with non-video urodynamics. Our experience over time has been that bladder dysfunction in CP is far more complex than generally thought, often involving DISD and prompting this review of our experience in evaluating these patients.
METHODS: The videourodynamic records of all 44 pediatric patients (age range 2.5-18) with CP in our IRB database were reviewed. It included 27males (mean age 11.9 yrs. range 2.5-18yrs.) and 17 females (mean age 7.4 yrs range 2.5-19 yrs.). The primary reason for initial referral was urinary incontinence (89%). Of the 44 patients, 19 (43%) were self referred, primarily because of urinary incontinence and nearly 3/4 were not receiving regular urologic care at the time of urodynamic referral. Only 3 had previously been evaluated urodynamically at other institutions and all were non-video studies.
RESULTS: Videourodynamic findings confirmed the presence of NDO in 39 (89%) including 11 without any associated sphincter dyssynergy. Sphincter dyssynergy was noted in 33/44 (75%)with DESD present in 13(30%) or 37% of sphincter dyssynergy overall. Whereas DISD was noted in 20 (45%) of all CP patients and represented 61% of all those with dyssynergy. In 3 children with DISD there was no associated detrusor over activity documented on UDS.
CONCLUSIONS: Nearly 90% of patients with CP experiencing incontinence have urodynamic evidence of neurogenic
detrusor overactivity and 3/4 of those have associated sphincter dyssynergia. This dyssynergy is most common, not at the external urethral sphincter as previously reported, but at the level of the internal sphincter/bladder neck and would have been missed without
videourodynamics. Underlying voiding dysfunction in CP patients is far more involved than previously reported and should prompt a more careful urodynamic evaluation prior to treatment,preferably with simultaneous fluoroscopy whenever possible.
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