Management of neurogenic bladder dysfunction secondary to myelomeningocele

MANAGEMENT OF NEUROGENIC DYSFUNCTION IN THE ADULT zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJ ALAN J. WEIN, M.D. DAVID M. RAEZER, GEORGE BLADDER S. BENSON, M.D. M.D. From the Division of Urology, Department of Surgery, University of Pennsylvania School of Medicine, and the Veterans Administration Hospital, Philadelphia, Pennsylvania zyxwvutsrqponmlkjihgfedcbaZYXW ABSTRACT - A review of the management of neurogenic bladder dysfunction in the adult is presented. The various modes of therapy are classi$ed according to their effects on bladder contractility and outlet resistance, providing a logical framework fm discussion. The purpose of this review is to discuss methods of managing traumatic and nontraumatic neurogenie bladder dysfunction in adults. Except in the case of a malignant spinal cord lesion or a progressive neuropathy, there is little difference in the prognosis or management of neuropathic bladder dysfunction of traumatic or nontraumatic etiology after the first three months have elapsed. lz Therefore, these modes of therapy are applicable to any such patient in whom balanced bladder function has not developed spontaneously after the period of spinal shock (if present initially) has passed. Although the goals of management are similar for adults and children, particular approaches vary (especially in the case of myelomeningocele), and the treatment of children with neurogenic bladder dysfunction will not be specifically discussed in this article. General Principles It is important to adopt a flexible approach that recognizes the importance of certain priorities and goals while taking into account the practicality of each proposed solution for the individual patient. 3,4 Although collective experience is valuable, no single schema, classification, protocol, or model is always reliable and appropriate. The patient’s total life situation and capabilities must be considered for example: 432 Prognosis of underlying disease, especially progressive or malignant disease Limiting factors: inability to perform certain tasks (use of hands, mobility) Motivation Reliability Intelligence, education, and educability Psychosocial environment: interest, reliability, and cooperation of family Economic resources. The same therapeutic measures may not be applicable to all patients with the same type of bladder dysfunction. Hospital resources and bed-use efficiency must also be considered, especially in situations in which the demand for rehabilitation beds is great. Although no two authors agree completely on specific goals in the management of neuropathic bladder dysfunction, the following common objectives are evident:5-16 Upper urinary tract preservation or improvement Absence or control of infection Adequate emptying at low intravesical pressure Avoidance of overdistention Adequate storage to prevent or lessen incontinence Adequate control No catheter or stoma Social acceptability/ adaptability Vocational acceptability/ adaptability. UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 2. Interruption of innervation (a) Subarachnoid block (b) Sacral rhizotomy From these objectives, the following indications for changing or augmenting a particular regimen are derived: Upper urinary tract deterioration Recurrent sepsis or fever of urinary origin Lower urinary tract deterioration Inadequate emptying Inadequate storage Inadequate control Skin changes secondary to incontinence or to a collecting device. A useful classification of the various types of therapy is based on how well the bladder performs its two functions - urine storage and emptying.5,“,8,‘5-‘7 The following outline summarizes measures to facilitate bladder emptying: B. Increase outlet resistance 1. At level of bladder neck stimulation (a) Alpha-adrenergic Mechanical compression (b) 2. At level of distal mechanism manipulation (a) Pharmacologic Mechanical compression C zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLK Electrical stimulation of pelvic floor i”l C. Circumvent problem 1. Intermittent catheterization 2. Urinary diversion A. Increase intravesical pressure zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Almost any pathologic alteration of micturition 1. External compression secondary to neurogenic dysfunction can be 2. Promotion or initiation of reflex conbroadly categorized in this manner. This aptractions proach stems from the simple but practical (a) Trigger zones or maneuvers idea” that the efficiency of micturition repre(b) Bladder training, tidal drainage sents a balance between (1) the forces of bladder 3. Pharmacologic manipulation expulsion, and (2) the forces of resistance, com(a) Parasympathomimetic agents prising the bladder neck and the “distal urethral (b) Blockers of inhibition (?) mechanism” I9 (the intrinsic urethral smooth 4. Electrical stimulation muscle and the extrinsic striated musculature of (a) Directly to bladder the pelvic floor). (b) To nerve root or spinal cord A combination of therapeutic maneuvers can sometimes be used to achieve a particular end, B. Decrease outlet resistance especially if they act through different mecha1. At level of bladder neck nisms. This approach often succeeds when a resection of bladder (a) Transurethral single method has failed. One should consider neck the possible effect of any therapeutic measure Y-V-plasty of bladder neck on related intact functions, such as sexual funcPharmacologic inhibition tion, and its potential reversibility. The simplest level of distal mechanism and least destructive mode of therapy should (a) External sphincterotomy generally be tried first. Well-balanced bladder Urethral overdilation function may become unbalanced in response to Pudendal nerve interruption relatively minor trauma, such as nonurinary Pharmacologic inhibition sepsis or infection, or surgery.6 In such a situa(1) External sphincter/pelvic floor tion the previous degree of bladder function will (2) Urethra normally be regained spontaneously, but additional therapeutic maneuvers may be required C. Circumvent problem even after the effects of the injury have disap1. Intermittent catheterization peared. 2. Urinary diversion. Finally, in considering the merits of various types of therapy, one must remember that there Therapy to facilitate urine storage is as follows: are no universal criteria by which the terms success, improvement, and failure are applied. A. Inhibit bladder contractility Long-term practical fulfillment of as many of the 1. Pharmacologic manipulation goals of management as possible with the least Anticholinergic agents number of unpleasant side effects should be the Beta-adrenergic stimulation (?) standard by which all forms of treatment are Musculotropic relaxants judged. Polysynaptic inhibitors NOVE4IBER 1976 / VOLCME VIII. NU\fBER 5 333 Therapy to Facilitate dwelling catheter and maintaining a copius fluid Bladder Emptying zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA intake either “conditions” the detrusor reflex or prevents bladder contracture. Such a regimen benefits the patient primarily by focusing his increasing intravesical pressure attention on his bladder and insuring an adequate fluid intake. 6-8 External compression. Voiding by abdominal straining, Valsalva, Crede, or with the use of Pharmacologic manipulation. Since the final an expression belt is unphysiologic and is recommon pathway in physiologic bladder consisted by the same forces that normally resist traction is stimulation of the cholinergic recepstress incontinence (the bladder neck and the tor sites at the postganglionic parasympathetic intrinsic urethral mechanism). 5,6,8,15To increase neuromuscular junction, it stands to reason that intravesical pressure in this manner requires parasympathomimetic agents should be useful voluntary control of the abdominal wall and diain the management of certain types of phragmatic muscles or, in the case of Crede, neurogenic bladder dysfunction.21-24 Acetyl,adequate hand control. Crede is more readily choline, thought to be the parasympathetic performed in a child than in an adult and is neurohumoral transmitter, cannot be used beeasier if the abdominal wall is lax rather than cause of its diffuse action (ganglionic and central taut and lean rather than obese. External comeffects) and its rapid hydrolysis by acetylpression is most effective in those patients with cholinesterase and nonspecific cholinesterase.25 a hypotonic or atonic bladder who can generate Bethanechol chloride (Myotonachol, Urechoa pressure greater than 50 cm. water with this line) is cholinesterase resistant and has a relamaneuver.20 If adequate emptying does not octively selective action on the smooth muscle of cur, procedures to decrease outlet resistance the gut and urinary bladder. It causes a contracmay be required, especially at the level of the tion in vitro of smooth muscle from all areas of bladder neck, which often does not open the bladder.26 This agent is useful in alleviating adequately with external compression. Vespostoperative urinary retention and may be icoureteral reflux is a relative contraindication to helpful in the management of chronic hypotonic this form of voiding, as upper tract damage can bladder dysfunction if irreversible changes of result if concomitant infection exists. bladder muscle decompensation have not occurred.21-25 It is most effective when given Promotion or initiation of rejex contracsubcutaneously in doses of 5 to 10 mg. Oral Manual stimulation of the sacral and tions. doses of less than 50 mg. are probably ineffeclumbar dermatomes (squeezing the glans penis tive in the adult.22*27 The use of bethanechol or clitoris, pulling the skin or hair of the pubis, chloride is generally contraindicated in cases of scrotum, or thigh, or digital rectal stimulation) known bladder outlet obstruction, but theoretican be used by patients with supranuclear lecally it can be combined with procedures desions in an attempt to provoke reflex bladder signed to decrease outlet resistance. We, as well contraction.5p6~8 According to Glahn20 the most as others2* have been generally unimpressed effective method consists of rhythmic suprawith the long-term effect of oral bethanechol pubic manual pressure (seven or eight pushes chloride on bladder emptying. We are also unevery three seconds), which is thought to proable to rationalize its use in combination with duce a summation effect on the tension recepintermittent catheterization in patients with tors in the bladder wall and activation of the supranuclear lesions who are in spinal shock unreflex arc via the afferent discharge produced. less it proves to facilitate the micturition reflex The optimal intravesical pressure so produced is arc. Since voiding produced by this drug is un60 to 70 cm. water. This procedure may have to physiologic, additional measures may be necesbe combined with measures to decrease outlet sary to achieve adequate emptying. resistance, especially at the level of the distal urethral mechanism, where functional obstrucIf the sympathetic nervous system can exert tion often exists in these patients. Some manual an inhibitory effect on parasympathetic dexterity and the presence of an external colganglionic transmission2’ and directly inhibit lecting device or excellent mobility are rebladder muscle contractility,30-32 adrenergic quired. blocking agents may be effective in increasing bladder contractility. Guanethidine has been There is no evidence that the establishment used with this rationale, although a subsequent of a rhythmic pattern of intake or output by report of its efficacy has not appeared.33 zyxwvutsrqponmlkjihg periodically clamping and unclamping an in- 434 UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 tients: (1) those with weak or absent detrusor stimulation. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Clinical trials of dicontractions, and (2) those with anatomic or functional obstruction at the level of the bladder neck and proximal urethra which prevents emptying even with a sustained detrusor contraction.5~8,‘2~‘5=47~4g The ideal patient is one with a sacral lesion and an areflexic bladder who can reported the results of clinical trials of newer, achieve a measurable increase in intravesical more reliable equipment. Direct electrical pressure by straining and/ or Credit but who stimulation was most effective in patients with cannot empty the bladder adequately by these hypotonic, areflexic bladders. A low postvoiding maneuvers. Some urologists still prefer to resect residual and sterile urine were initially achieved the bladder neck whenever signs of outlet in 5 of the 10 patients in Halverstadt and Parry’s obstruction are associated with a neuropathic series and in 3 of the 5 patients in Merrill’s bladder, and treat other areas of outlet resistseries. Secondary failure, usually related to ance later, if this proves necessary.20,48 In a paequipment malfunction, occurred in three of tient with a suprasacral lesion whose bladder is Halverstadt’s patients. The primary failure rate still areflexic after three months, but in whom is higher in patients with supranuclear lesions reflex contractions are expected to develop who have reflex detrusor contractions, and dieventually, resection may be done to facilitate rect electrical stimulation is not recommended early catheter removal; this can be followed, if for this group unless conversion to an areflexic necessary, by a procedure to decrease resistance bladder is first achieved neurosurgically. Side at the level of the distal mechanism.13J5 effects and complications are frequent and are generally related to equipment failure. The Techniques of resection include: (1) a spread of current to other pelvic structures thorough circumferential resection of all tissue whose stimulus thresholds are lower than that of between the internal orifice and the verumonthe detrusor can result in abdominal, pelvic, and tanum; (2) a limited resection of dorsal tissue perineal pain, a desire to defecate, contraction from the 3-o’clock through 9-o’clock position; (3) of pelvic and leg muscles, and erection and a resection further limited to the posterior lip; ejaculation. Since the increase in intravesical and (4) transurethral incisions of the bladder pressure is not coordinated with bladder neck neck at the 5-o’clock and ‘i-o’clock positions. It is opening or pelvic floor relaxation, concomitant generally agreed that any prostatic tissue promeasures to accomplish these ends may be lapsing into the lumen after the resection should necessary. be removed. Under-resection rather than overA very interesting approach to this problem resection is generally advised, since multiple rehas been adopted by Grimes and his assections involve little morbidity. sociates.44’45 In a series of 10 carefully selected Satisfactory results occur in 60 to 90 per cent they applied a stimulator paraplegic patients, of patients selected and treated in this mandirectly to the sacral cord, taking advantage of ner 78,47,48 comprising 10 to 20 per cent of all the remaining intact motor pathways to initiate patients with neurogenic bladder dysfunction in voiding. Since this stimulus is also unphysiologmost authors’ series. Hemorrhage, extravasaic, many of the side effects seen with direct tion, epididymo-orchitis, and other complicabladder stimulation occurred. However, 6 of tions are uncommon. The operation can be perthese patients were successfully treated by this formed in children.50 It is seldom necessary in procedure, although 2 required ancillary treatfemales. ment to decrease outlet resistance. Y-V-plasty of bladder neck. A simple Y-V- Electrical rect electronic vesical stimulation originated in 194034 but have met with only partial success and intermittent enthusiasm since that time.35-3g Recently, Merrill and Conway,40-42 and Halverstadt and Parry43 reviewed the literature and Transurethral resection of the bladder performed the first transEmmett46 neck. urethral bladder neck resection in a patient with neurogenic bladder dysfunction in 1937, and for years this procedure represented the first line of surgical attack in cases of poorly balanced bladder function. The current view is that this operation is useful primarily for two groups of pa- plasty of the bladder neck can accomplish the same effect as a transurethral resection and is especially appropriate when an open surgical procedure is required to correct a concomitant disorder, such as vesicoureteral reflux.8*48,50 It is rarely performed as an independent procedure. A radical Y-V-plasty of the bladder neck can be used to render a refractory, poorly emptying bladder totally incontinent, a condition which can then be managed by an external collection UROLOGY 5 Decreasing outlet resistance / NOVEMBER 1976 / VOLUME VIII. NUMBER 435 device or by the implantation of a prosthetic sphincterotomy may be used as an adjunct sphincter. 51,52 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA measures to increase intravesical pressure. Pharmacologic inhibition of bladder The fact that certain sympatholytic drugs neck. (reserpine and phenoxybenzamine hydrochloride) may facilitate voiding in certain patients was first noted in 1970 by Kleeman.53 Krane and 01sson54,55 subsequently further described a physiologic internal sphincter which is contributed to at least partly by a tonic neurogenic effect on alpha-adrenergic receptors in the smooth muscle of the bladder neck and They successfully used proximal urethra. phenoxybenzamine, an alpha-adrenergic blocking agent, to correct a specific type of emptying failure secondary to neuropathic bladder dysfunction. Six patients without prostatic hypertrophy and without a spastic external sphincter who could not void effectively with cholinergic stimulation were treated with phenoxybenzamine, 10 to 30 mg. daily, alone or together with bethanechol chloride. All but one of these patients established good voiding patterns that persisted for up to fifteen months. Additional reports of successful alpha-adrenolytic therapy, both in adults and in children (given 0.3 to 0.5 mg. of phenoxybenzamine per kilogram body weight per day) have appeared,50,56,57 and the number will undoubtedly increase. Side effects include drowsiness and orthostatic hypotension, both of which tend to lessen with time, and loss of ejaculatory ability. External sphincterotomy. Therapeutic destruction of the external urethral sphincter was first performed in 193658 in a patient with nonspastic obstruction. Although this procedure was mentioned again in 1943,5g the first large clinical series was reported in 1958 by Ross, Gibbon, and Damanski.” Their series has subsequently been expanded to more than 150 patients,61,62 and other large63+!5 and smalleP6* series have been reported. The primary indication for this procedure is the failure of the bladder to empty in a patient with a suprasacral lesion and good detrusor contractions where prostatic obstruction and obstructive inflammatory lesions at the bladder neck have been ruled out.62 Cystourethrograp hit demonstration of obstruction at the level of the external sphincter in these patients 61 has been confirmed by urethral pressure profile studies pre- and postoperatively. 6g,70In patients with sacral lesions, if procedures designed to decrease resistance at the bladder neck fail to produce adequate emptying at low intravesical pressures,62 external 436 to Techniques of resection vary. Gibbon13,62 makes incisions at the 5-o’clock and 7-o’clock positions with a knife electrode using minimal coagulating current. Schellhammer, Hackler, and Bunts64,65 recommend making incisions from just proximal to the verumontanum to the proximal bulbous urethra at the &o’clock and 9-o’clock positions with a cutting current followed by coagulation. Other techniques include incisions at 2, 4, 8, and 10 o’clock;14 at 11 and 1 o’clock;71 and a single incision at the I2-o’clock position. ‘* The presence of collapsed apical prostatic tissue in the fossa after posterolateral incisions have been made usually calls for resection. Repeat sphincterotomy may be necessary due to initial or late failure. A substantial improvement in bladder emptying has occurred in 70 to 90 per cent of reported cases. 13~14,61-68 Upper tract deterioration is rare after a successful sphincterotomy, and vesicoureteral reflux, if present, often disappears because of lower voiding pressures and the reduced incidence of infection in a catheterless patient with a low residual urine. An external collecting device is generally worn postoperatively. Disagreement exists, however, as to the incidence of total dripping incontinence or severe stress incontinence. Some authors62,73 claim that these conditions are rare, other?* report an incidence approaching 80 per cent, and many make no comment whatever about postoperative incontinence. Since most of the patients selected to undergo this procedure have preoperative incontinence secondary to reflex contractions only, and have a competent bladder neck and intrinsic urethral mechanism, the occurrence of these types of incontinence after division of only the external striated sphincter is puzzling. In fact, reflex incontinence may be less likely postoperatively, since with better emptying the threshold pressure for eliciting a reflex contraction will be reached less frequently. Other complications of sphincterotomy include hemorrhage and urinary extravasation (both uncommon). Recently, erectile impotence has been reported. In one retrospective study74 impotence was noted in 8 of 25 patients. Kiviat’l reported a 29-per cent incidence of permanent impotence after a 3- and 9-o’clock sphincterotomy and attributed it to injury to the deep and dorsal corporal arteries. None of his patients who had incisions at the ll- and I-o’clock posi- zyxwvutsrqpon UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 doses required to control the skeletal spasticity associated with suprasacral spinal cord lesions. reflexogenic erections, either spontaneous or due to external stimulation, occur in more than Dantrolene sodium (Dantrium), a relatively new skeletal muscle relaxant, has a direct action on 90 per cent of patients with suprasacral spinal and prosskeletal muscle and appears to alleviate the cord injuries, ‘5 further retrospective spasticity associated with upper motor neuron pective investigation into the true incidence of lesions.82 It has no autonomic side effects, but it iatrogenic impotence with different techniques does tend to induce a generalized weakness of and types of current is definitely warranted. If the skeletal musculature, which may be severe only the external sphincter is severed, it is enough to compromise its therapeutic benefits. difficult to theorize a mechanism whereby the Whether or not it will prove useful in treating ability to achieve an erection would be compromised. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA spasticity of the periurethral striated muscle remains to be seen. UrethruZ overdilation. External sphincterotSome patients with an areflexic bladder and a omy is seldom necessary in females, since ureflaccid pelvic floor due to a conus or cauda thral overdilation to 40 to 50 F usually achieves equina lesion can open the bladder neck by the same objective. I3 In young boys a similar straining but are unable to empty the bladder stretching of the posterior urethra can be acbecause of a functional obstruction in the poscomplished through a perineal urethrostomy, terior urethra. In a recent report of such paobviating or postponing the need for a tients, alpha-adrenergic blockade with phensphincterotomy. 5o tolamine (Regitine) resulted in relaxation of this Pudendal nerve interruption. Relief of an area and adequate emptying.83 This result indiobstruction at the level of the striated external cates that at least some of the outflow resistance sphincter can also be achieved by a pudendal in the posterior urethra involves smooth muscle in 1899 by neurectomy, first d escribed under alpha-adrenergic stimulation, an idea Rochet.‘6 This procedure can be used especially originally suggested by Donker, Ivanovici, and in children, in whom external sphincterotomy Noach.84 More sophisticated methods of diagmay be difficult, 76,77 and is also useful in nosing the level of functional obstruction may adults.7” -81 According to Engel and Schirmer,‘l help to identify those patients likely to benefit the most suitable patient is one with a supranuby this form of treatment. clear lesion, a good detrusor reflex, clear evidence of outflow obstruction, and a voiding patlntermittent catheterization tern that improves after a unilateral pudendal block. In their series of 23 such patients, zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 18 had Intermittent catheterization has proved to be excellent results after a unilateral pudendal the most effective means of attaining a catheterneurectomy that severed only the median free state in the majority of patients with acute branch of the nerve supplying the external urespinal cord lesions. 85-88 It is also an effective thral sphincter. Bilateral nerve section results in method of treating the adult or child whose an unacceptably high rate of impotence and bladder fails to empty, especially when efforts to sometimes in fecal and urinary incontiincrease intravesical pressure and decrease outnence 8,13,15,81 let resistance have been unsuccessfu18’ In those Pharmacologic inhibition of distal urethral patients who have inadequate urine storage or mechanism. Unfortunately, there is no pharreflex or stress incontinence with inadequate maceutical agent that will selectively relax the emptying, it may also be used successfully if the musculature of the pelvic floor. Although cendysfunction can be converted pharmacologically trally acting muscle relaxants, such as diazepam or surgically solely to one of emptying.8g-g3 In(Valium) and chlordiazepoxide hydrochloride termittent catheterization requires a cooperative, well-motivated patient or family. It is (Librium), methocarbamol (Rbbaxin), and ordifficult to accomplish if the patient lacks hand phenadrine citrate (Norflex), are used to inhibit control or cannot achieve adequate urethral exskeletal spasm,8’82 spasticity of the external ureposure because of pronounced spasticity of the thral sphincter is rarely controlled on a longleg muscles. We have been satisfied with clean term basis with any of these drugs alone. rather than sterile catheterization. Close Though free of autonomic side effects, all of follow-up is necessary. Patients should be mainthem commonly produce sedation and drowsitained on urinary suppressive medication, and zyxwvutsrqpo ness, especially when taken in the large oral tions was IJROLOCY impotent / NO\‘E\4BEK postoperatively. 1976 / V O LUM E Since VIII, NUM BER 5 ‘I37 acute symptomatic infections should be store urine adequately to one that fails to promptly and appropriately managed. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA empty, a condition that can then be corrected by external compression termittent catheterization. Urinary diversion As a last resort, continuous catheterization or urinary diversion may be necessary to circumvent emptying or storage failure. Therapy to Facilitate Urine Storage Inhibiting bladder contractility Pharmacologic manipulation. Atropinic and antimuscarinic agents produce a competitive blockade of acetylcholine receptors, primarily at postganglionic autonomic effector sites.94 Propantheline bromide (Pro-Banthine) is the agent most commonly used to achieve this effect; it does, however, possess some ganglionic blocking (nicotinic) activity. Propantheline bromide is used primarily to block uninhibited bladder maneuvers 16*go,g8The or by inusual dos- age of imipramine is 25 mg. four times daily in adults and 5 to 10 mg. four times daily (not to exceed 1.5 to 2 mg. per kilogram per dose) in children. Side effects include dry mouth, blurred vision, constipation, tachycardia, excessive sweating, fatigue, tremor, and headache. Ephedrine, which causes the peripheral release of norepinephrine as well as direct stimulation of alpha and beta receptors,lo4 would be expected to facilitate urine storage in the same manner as imipramine. Its clinical effectiveness in the treatment of incontinence has been ascribed to stimulation of alpha receptors in the urethra, lo5 and no effect on detrusor hypertonicity has been reported. Perhaps the effect of imipramine on hypertonicity is due to the intracellular inhibition previously mentioned rather than to a beta-adrenergic effect on the musculature of the bladder corpus. contractions in adults and children.23,94,g5 The Musculotropic relaxants such as flavoxate 15 mg. every four to six usual initial dosage is zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA hydrochloride (Urispas)‘06~‘07 and oxybutynin hours in adults and 7.5 mg. every four to six chloride (Ditropan)‘08*10g are thought to act dihours in children. rectly on smooth muscle at an intracellular site Imipramine hydrochloride (Tofranil) has distal to the cholinergic receptor mechanism.lo3 proved useful in decreasing detrusor hyperPolysynaptic inhibitors such as hydramitrazine tonicity in adults and children,g6-g8 as well as in (Lisidonil)23 and lioresol, a derivative of gamma the management of enuresis. gg~looIts peripheral aminobutyric acid, ‘lo are thought primarily to action on the bladder may be due to a block of exert an inhibitory effect on shinal internorepinephrine reuptake by adrenergic nerve neurones without affecting neuromuscular terminals (an effect as yet demonstrated only in transmission. Although some clinical sucthe central nervous system). lo1 Theoretically, cess23,110 has been claimed with both classes of stimulation of the predominantly betainhibitors, additional double-blind studies are adrenergic receptors in the bladder corpus needed to prove their value in the treatment of would decrease smooth muscle tone and inuninhibited contractions and detrusor hypercrease the accommodation capacity.26,2g-32 A tonicity in neuropathic bladder disease. similar stimulation of the bladder base and proximal urethra, where alpha receptors predominate, would augment the activity of the physiologic internal sphincter. 26,53V55*102,103 Both of these effects would tend to promote urine storage. Imipramine may also have a direct inhibitory intracellular effect, for it has been shown to block the response of bladder muscle in vitro to both bethanechol chloride and barium chloride.‘03 In our experience it has been especially useful when inadequate urine storage has been secondary to bladder hypertonicity rather than to uninhibited contractions. 16,g8 If both conditions exist, imipramine may be administered along with propantheline bromide. We have found this combination especially useful in converting a bladder that fails to 438 Interruption of innervation. Subarachnoid alcohol block is not used solely for urologic indications but is used to convert a state of severe somatic spasticity to flaccidity and to abolish autonomic dysreflexia. 5-8 As a byproduct, a reflex neurogenic bladder will usually be converted to an areflexic autonomous one which can be emptied by methods described previously or by intermittent catheterization. In 8 of 29 patients in Gibbon’s7 series and in 7 of 11 patients in that of Misak et al. ‘11 an autonomous bladder developed that emptied without further surgical or medical treatment. Additional therapy, when necessary, was directed at increasing intravesical pressure and decreasing outlet resistance. The presence of a well-balanced reflex bladder zyxwvutsrqpon UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 is a contraindication to this nonselective There proce- dure, as is the ability to achieve an erection, function usually lost as a result.5-8 a is no drug available that will selectively increase the contractility of the striated pelvic floor and periurethral musculature. Electrical stimulation of these structures to produce contibilateral anterior and posterior or conusectomy will also connence has been tried since 1963.“ * Since, as Merrill, Conway, and DeWolfng have pointed hypertonic bladder to an vert a hyperreflexic, out, the stimulation is not to the pelvic floor autonomous one.“ 1,“ 2 Adequate emptying was musculature directly but indirectly through the achieved in 23 of 28 such patients treated by motor pudendal nerve, the lack of success in Misak et al.“ ’ but 13 required subsequent treating patients with lower motor neuron lecatheterization because of persistent vesicouresions is not surprising. Such a device would also teral reflux, or hypersensitivity to or technical be of limited use in patients with complete difficulty with the required collecting device. upper motor neuron lesions, who are incontiErections were lost or impaired in 85 per cent nent because of reflex contractions and usually of patients who were potent preoperatively. A already have pelvic floor spasticity. Merrill and temporary impairment of bowel function, lasting his associates do not recommend the use of elecsix to twelve weeks, also occurred posttronic stimulation to produce continence in paoperatively. Selective sacral nerve section is thought to intients with paraplegia and myelomeningocele. crease bladder capacity by abolishing only the Spotty disease of the corticoregulatory tracts with uninhibited contractions appears to be the motor supply responsible for uninhibited contractions, leaving sphincter and sexual function only type of neuropathic bladder dysfunction to which this technique is applicable. intact. The initial use of this procedure followed the observation by Heimburger, Freeman, and Wilde in 1948113 that the third sacral anterior Problem of Vesicoureteral Reflux root provides the dominant motor innervation of the human bladder. To enhance the clinical reThe potentially deleterious effects of vessponse and minimize side effects, differential icoureteral reflux on the upper tracts of patients sacral rhizotomy should be preceded by stimulawith neuropathic bladder dysfunction, espetion and blockade of the individual sacral roots cially those with poor voiding ability and infecwith cystometric and sphincterometric control. tion, are emphasized by Donnelly, Hackler, and Rockswold, Bradley, and Chou114 and Torrens Buntseg The true incidence of reflux in these paand Griffithn5 described their experiences with tients is unknown, and estimates range from as differential sacral rhizotomy. Of Torrens’ 9 low as 7 per cent to as high as 38 per cent8-10 cases, 2 were unequivocal failures, 2 were sucReflux is usually reversible if infection is eradicesses, and 5 were “ improved.” No significant cated and efficient voiding at low intravesical postoperative disturbance of bowel or sexual pressures restored. 13~15~120 Hackler,” however, function occurred. This procedure would apestimated that there is a 15-per cent incidence pear, however, to be of limited value in treating of irreversible reflux after five to ten years of patients with increased outflow resistance unless paraplegic life. If conservative therapy fails, this, too, is reduced or eliminated. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA surgical intervention is indicated in selected In most cases sacral rhizotomy Increasing outlet resistance Pharmacologic manipulation directed at the bladder neck and urethra (alpha-adrenergic stimulation) has already been mentioned. A prosthetic sphincter may be used to produce continence by means of mechanical compression at the level of the bladder neck or urethra.116,117 However, all 7 failures in Scott’s” 6 initial series of 34 patients occurred in those with neurogenic bladder dysfunction. Marked detrusor hyperreflexia will cause cuff deflation and leakage, and satisfactory results are achieved in these patients only if they are first rendered totally incontinent. UROLOGY I NOVEMBER1976 I VOLUMEVIII, NUMBER5 cases, even though the success rate is not as great as in patients without neuropathic bladders.‘20J21 Using a modification of the Hutch I procedure in patients with good bladder capacities (150 cc.), well-balanced bladder function, and normal upper tracts, Reece and Hackler12* achieved an impressive success rate of 73 per cent in 92 refluxing units. The serious potential of vesicoureteral reflux is demonstrated by the fact that in 80 per cent of the 27 renal units that continued to reflux in this series, upper tract deterioration developed despite catheter drainage. In those patients having a successful antireflux procedure, more than 90 per cent of the renal units remained stable. If 439 reflux persists on one side, a transureteroureterostomy can be done. Hackle?’ reported renal deterioration in only 1 of 11 such cases. Advocacy of antireflux procedures in patients with neuropathic bladder dysfunction is by no means universal, however. Bors and Comarr* are among those who advise against this mode of treatment. Place of Continuous Catheter Drainage and Urinary Diversion Continuous catheter drainage or urinary di- version is seldom necessary in patients with neurogenic bladder disease and is considered a last resort. Unequivocal indications include upper urinary tract deterioration or deleteriously poor emptying that cannot be reversed or stabilized by more conservative therapy directed at the bladder or outlet.‘3~15~‘22~123 Unmanageable vesicoureteral reflux with infection usually leads to renal deterioration and therefore necessitates some form of continuous drainage. The presence of an abscess or fistula that makes the lower urinary tract unusable as a reservoir or conduit obviously calls for supravesical diversion. Intractable, intolerable incontinence, especially in a female, may also be a reasonable indication for diversion or catheter drainage. For patients who have progressive or malignant disease or uremia, or who are unable or unwilling to undergo certain surgical procedures, a permanent indwelling catheter may be necessary and preferable. Gibbon13 found this to be necessary in 4 per cent of his patients. If a cutaneous ureterostomy is not possible, ureteroileostomy, first performed in 1935 and popularized in 1950, lz4 has become the standard by which all other forms of supravesical diversion are judged. lz2 Although numerous wellknown complications of the urinary and intestinal tracts may occur, this procedure is usually satisfactory in terms of upper tract stabilization or improvement. 122-127 The colonic conduit, especially with an antireflux ureteroenteral anastomosis (possible only with undilated ureters), may prove to have fewer complications. l**13* It should be noted, however, that the percentage of patients having subsequent upper tract deterioration (determined by radiographic and chemical criteria) after an ileal conduit depends on the length of the postoperative follow-up period. 133 Ten to fifteen years must elapse before the final attributes of any supravesical diversion can be evaluated, especially 440 since this time period represents the peak incidence of renal deterioration, at least after spinal cord injuries.* In most recently reported large series, the percentage of adults undergoing urinary diversion for neurogenic bladder dysfunction is low, ranging from 1 to 3 per cent.10,‘3,14 This procedure can be expected to remain infrequent owing to a more sophisticated appreciation of the neuromuscular and neuropharmacologic factors responsible for inadequate bladder emptying or storage and more precise methods of diagnosis and treatment. Hospital of the University of Pennsylvania Suite W-310 White Building Philadelphia, Pennsylvania 19104 (DR. WEIN) References 1. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGF TRIBE, C. R., and SILVER, J. R.: Renal Failure in Paraplegia, London, Pitman Co., 1969. 2. JAMESON, R. M.: Management of the bladder in non-traumatic paraplegia, Paraplegia 12: 92 (1974). 3. BOYARSKY, S. : The neurogenic bladder (editorial comment), in Boyarsky, S., Ed.: The Neurogenic Bladder, Baltimore, Williams and Wilkins Company, 1967, p. 183. approach to 4. TALBOT, H. S.: The physiological neurogenic vesical dysfunction, in Boyarsky, S., Ed. : zyxwvutsrqpon ibid. ,3 pp. 183-186. Neurogenic bladder, Urol. Surv. 7: 177 5. BORS, E.: (1957). 6. COMARR, A. E.: The practical urologic management of the patient with spinal cord injury, Br. J. Urol. 31: 1 (1959). 7. GIBBON, N.: Management of the bladder in acute and chronic disorders of the nervous system, Acta Neurol. Stand. [Suppl.] 42: 133 (1966). 8. BORS, E., and COMARR, A. E.: Neurological Urology, Baltimore, University Park Press, 1971. 9. DONNELLY, J., HACKLER, R. H., and BUNTS, R. c.: Present urologic status of World War II paraplegic: 25-year followup. Comparison with status of the 20-year Korean War paraplegic and 5-year Vietnam paraplegic, J. Urol. 108: 558 (1972). Spinal cord injuries: urologic 10. HACKLER, R. H.: care, Urology 2: 13 (1973). 11. LAPIDES, J.: Neurogenic bladder: principles of treatment, Urol. Clin. North Am. 1: 81 (1974). 12. ROSSIER, A. B.: Neurogenic bladder in spinal cord injury: management of patients in Geneva, Switzerland and West Roxbury, Massachusetts, ibid. 1: 125 (1974). 13. GIBBON, N. 0. K.: Neurogenic bladder in spinal cord injury: management of patients in Liverpool, England, ibid. 1: 147 (1974). 14. O’FLYNN, I. D.: Neurogenic bladder in spinal cord injury: management of patients in Dublin, Ireland, ibid. 1: 135 (1974). 15. GIBBON, N. 0. K.: Later management of the paraplegic bladder, Paraplegia 12: 87 (1974). 16. DUCKETT, J. W., JR., and RAEZER, D. M.: Neuromuscular dysfunction of the urinary bladder, in UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. SCOTT, F. B., QUESADA, E. M., CARDUS, D., and Kelalis, P. P., and King, L. R., Eds.: Pediatric UrolLASKOWSKI, T. : Electronic bladder stimulation: ogy, Philadelphia, W. B. Saunders, in press. QUESADA, E. M., SCOTT, F. B., and CARDUS, D.: dog and human experiments, Invest. Urol. 3: 231 (1965). Functional classification of neurogenic bladder dyswith a radio 38. HALD, T., et (I/. : Clinical experience function, Arch. Phys. Med. Rehabil. 49: 692 (1968). linked bladder stimulator, J. Urol. 97: 73 (1967). EMMETT, J. L.: Urinary retention from imbalance 39. STENBERG, C. C., BURNETTE, H. W., and BUNTS, of detrusor and vesical neck: treatment by transureR. C.: Electrical stimulation of human neurogenic thral resection, J. Urol. 43: 692 (1940). bladders: experience with four patients, ibid. 97: 79 TURNER-WARWICK, R. T., and WHITESIDE, C. G.: Investigation and management of bladder neck (1967). 40. MERRILL, D. C., and CONWAY, C. J.: Clinical exdysfunction, in Riches, E., Ed.: Modern Trends in perience with the Mentor bladder stimulator. I. PaUrology - 3, New York, Appleton-Century-Crofts, tients with upper motor neuron lesions, ibid. 112:52 1970, pp. 295-311. (1974). GLAHN, B. E.: Neurogenic bladder in spinal cord injury: management of patients in Hornback, Den41. MERRILL, D. C.: Clinical experience with the mark, Urol. Clin. North Am. 1: 163 (1974). Mentor bladder stimulator. II. Meningomyelocele LEE, C. W.: The clinical use of urecholine in dyspatients, ibid. 112: 823 (1974). function of the bladder, J. Urol. 62: 300 (1949). 42. IDEM: Clinical experience with the Mentor bladder LAPIDES, J., et zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA al. : Further observations on pharstimulator. III. Patients with urinary vesical macologic reactions of the bladder, ibid. 79: 707 hypotonia, ibid. 113:335 (1975). (1958). 43. HALVERSTADT, D. P., and PARRY, W. L.: ElecPEDERSEN, E., and GRYNDERUP, V.: Clinical tronic stimulation of the human bladder: 9 years lapharmacology of the neurogenic bladder, Acta ter, ibid. 113: 341 (1975). Neurol. Stand. [~uppl.] 42: 111 (1966). 44. GRIMES, J. H., NASHOLD, B. S., and CURRIE, D. URSILLO, R. C.: Rationale for drug therapy in P.: Chronic electrical stimulation of the paraplegic bladder dysfunction, in Boyarsky, S., Ed., ibid. ,3 pp. bladder, ibid. 109: 242 (1973). 187- 190. 45. GRIMES, J. H., NASHOLD, B. S., and ANDERSON, E. KOELLE, G.: Parasympathomimetic agents, in E.: Clinical application of electronic bladder stimuGoodman, L. S., and Gilman, A., Eds.: The Pharlation in paraplegics, ibid. 113:338 (1975). macologic Basis of Therapeutics, New York, Macmil46. EMMETT, J. L.: Transurethral resection in treatlan Company, 1975, pp. 467-476. ment of true and pseudo cord bladder, ibid. 53: 4 RAEZER, D. M., WEIN, A. J., JACOBOWITZ, D., and (1945). CORRIERE, J. N.,_ JR.: Autonomic innervation of 47. GIBBON, N. 0. K., Ross, J. C., and DAMANSKI, canine urinary bladder, Urology 2: 211 (1973). reM. : Bladder neck resection in the paraplegic: LAPIDES, J., FRIEND, C. R., AJEMMIAN, E. P., and port of over 100 cases, Paraplegia 2: 264 (1965). SONDA, L. P.: Comparison of action of oral and 48. BUNCE, P. L.: Transurethral resection and Y-Vparenteral bethanechol chloride upon the urinary plasty for neurogenic bladder, in Boyarsky, S., Ed., bladder, Invest. Urol. 1: 94 (1963). ibid. ,3 pp. 196- 199. GIBBO~V, N. 0. K: Urinary incontinence in disor49. TSUJI, I., NAKAJIMA, F., NISHIDA, T., and ABE, ders of the nervous system, Br. J. Ural. 37: 624 N.: Neurogenic bladder in spinal cord injury: man(1965). agement of patients in Hokkaido, Japan, Urol. Clin. DE GROAT, W. C., and SAUM, W. R.: Adrenergic North Am. 1: 139 (1974). inhibition in mammalian parasympathetic ganglia, Congenital 50. JOHNSTON, J. H., and FARKAS, A.: Nature New Biol. 231: 188 (1971). neuropathic bladder: practicalities and possibilities of EDVARDSEN, P.: Nervous control of the urinary conservational management, Urology 5: 719 (1975). bladder in cats, Acta Neurol. Stand. 43: 343 (1967). 51. SCOTT, F. B., BRADLEY, W. H., and TIMM, G. LEONI, J. V., WEIN, A. J., RAEZER, D. M., and W.: Treatment of urinary incontinence by an imSCHOENBERG, H. W.: The effect of beta adrenergic plantable prosthetic urinary sphincter, J. Urol. 112: stimulation on the contractile response of canine de75 (1974). trusor muscle, Invest. Ural. 10: 419 (1973). 52. ALLEN, T. D.: Neurogenic bladder of paraplegic innervation and WEIN, A. J., et al. : Sympathetic patient: management with radical Y-V-plasty, Urolchemical sympathectomy of canine bladder, Urology ogy 5: 216 (1975). 4: 27 (1974). 53. KLEEMAN, F. J. : The physiology of the internal uriHARTVIKSEN, K.: Discussion, Acta Neurol. Stand. nary sphincter, J. Urol. 104: 549 (1970). [Suppl.] 42: 180 (1966). 54. KRANE, R. J., and OLSSON, C. A.: PhenoxybenDEES, J. D.: Contraction of the urinary bladder zamine in neurogenic bladder dysfunction. I. A theory of micturition, ibid. 110: 650 (1973). produced by electric stimulation: preliminary report, Invest. Urol. 2: 539 (1965). 55. IDEM: Phenoxybenzamine in neurogenic bladder ibid. 110: dysfunction. II. Clinical considerations, BRADLEY, W., CHOU, S., and FRENCH, L.: Further 653 (1973). experience with the neurotransmitter receiver unit for the neurogenic bladder, J. Neurosurg. 20: 953 56. STOCKAMP, K. : Treatment with phenoxybenzamine (1963). of upper urinary tract complications caused by intravesical obstruction, ibid. 113: 128 (1975). BOYCE, W. H., LATHEM, J. E., and HUNT, L. D.: Research related to the development of an artificial 57. STOCKAMP, K., and SCHREITER, F.: Alpha adelectrical stimulator for the paralyzed human bladrenolytic treatment of the congenital neuropathic der: a review, J. Urol. 91: 41 (1964). bladder, Urol. Int. 30: 33 (1975). UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 441 58. WATKINS, R. H.: 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 442 The bladder function in spinal in79. BORS, E., and COMARR, A. E.: Effect of pudendal jury, Br. J. Surg. 23: 734 (1936). nerve operation on the neurogenic bladder, ibid. 72: BAUMRAUCKER, G. 0.: Management of the 666 (1954). paralyzed bladder, Arch. Surg. 56: 484 (1948). 80. KLEEMAN, F. J., and CHUTE, R.: A plan for the Ross, J. C., GIBBON, N. 0. K., and DAMANSKI, evaluation of patients with bladder dysfunction and M.: Division of the external urethral sphincter in the use of pudendal neurectomy in selected cases, the treatment of the paraplegic bladder: a prelimiibid. 97:1029 (1967). nary report on a new procedure, Br. J. Urol. 30: 294 81. ENCEL, R. M. E., and SCHIRMER, H. K. A.: Pu(1958). dendal neurectomy in neurogenic bladder, ibid. 112: IDEM: Division of the external sphincter in the 57 (1974). treatment of the neurogenic bladder: a ten year re82. FRANZ, D. N.: Drugs for Parkinson’s disease: centrally acting muscle relaxants, in Goodman, L. S., view, ibid. 30: 294 (1958). GIBBON, N. 0. K.: Division of the external sphincand Gilman, A., Eds., ibid.,25 pp. 221-244. ter, ibid. 45: 110 (1973). 83. ABEL, B. J., JAMESON, R. M., GIBBON, N. 0. K., and KRISHNAN, K. R.: The neuropathic urethra, CURRIE, R. J., BILBISI, A. A., SCHIEBLER, J. C., and Lancet 2: 1229 (1974). BUNTS, R. C.: External sphincterotomy in para84. DONKER, P. J., IVANOVICI, F., and NOACH, E. plegics: technique and results, J. Urol. 103: 64 L.: Analyses of the urethral pressure profile by (1970). means of electromyography and the administration of SCHELLHAMMER, P. F., HACKLER, R. H., and drugs, Br. J. Urol. 44: 180 (1972). BUNTS, R. C.: External sphincterotomy: an evalua85. GUTTMAN, L.: Spinal cord injuries: discussion on tion of 150 patients with neurogenic bladder, ibid. the treatment and prognosis of traumatic paraplegia, 110: 199 (1973). Proc. Roy. Sot. Med. 40: 219 (1949). IDEM: External sphincterotomy: rationale for the 86. GUTTMAN, L., and FRANKEL, H. L.: The value of procedure and experience with 150 patients, Paraintermittent catheterization in the early management plegia 12: 5 (1974). of traumatic paraplegia and tetraplegia, Paraplegia 4: MALAMENT, M.: External sphincterotomy in 63 (1966). neurogenic bladder dysfunction, J. Urol. 108: 554 catheterization for the 87. COMARR, A. E. : Intermittent (1972). traumatic cord bladder patient, J. Ural. 108: 79 KOONTZ, W. W., JR., SMITH, M. V. J., and CURRIE, . External sphincterotomy in boys with menin(1972). ior&elocele, ibid. 108:649 (1972). 88. FRANKEL, H. L.: Intermittent catheterization, Urol. Clin. North Am. 1: 115 (1974). HERR, H. W., ENGLEMAN, E. R., and MARTIN, D. C.: External sphincterotomy in traumatic and non89. LAPIDES, J., DIOKNO, A. C., LOWE, B. S., and ibid. 113: traumatic neurogenic bladder dysfunction, zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA KALISH, M. D.: Follow-up on unsterile, intermit32 (1975). tent self-catheterization, J. Urol. 111: 184 (1974). ROSSIER, A. B., and OTT, R.: Urinary manometry 90. WEIN, A. J., RAEZER, D. M., BENSON, G. S., and in spinal cord injury: a followup study. Value of cysMURPHY, J. J.: At-home intermittent self catheteritosphincterometrography as an indication for zation in the treatment of patients with neuromuscusphincterotomy, Br. J. Urol. 46: 439 (1974). lar bladder dysfunction, Proc. Kimbrough Ural. ABEL, B. J., Ross, J. C., GIBBON, N. 0. K., and Sem. 8: 41 (1974). JAMESON, R. M.: Urethral pressure measurement 91. RABINOVITCH, H. H.: Bladder evacuation in child after division of the external sphincter, Paraplegia 13: with meningomyelocele, Urology 3: 425 (1974). 37 (1975). 92. LYON, R. P., SCOTT, M. P., and MARSHALL, S.: Transurethral sphincterotomy: relaKIVIAT, M.: Intermittent catheterization rather than urinary ditionship of site of incision to postoperative potency version in children with myelomeningocele, J. Urol. 113: 409 (1975). and delayed hemorrhage, J. Urol. 114: 399 (1975). MADESBACHER, H., and SCOTT, F. B.: Twelve 93. HERR, H. W.: Intermittent catheterization in o’clock sphincterotomy: technique, indications, reneurogenic bladder dysfunction, ibid. 113: 477 sults, Urol. Int. 30: 75 (1975). (1975). SCHELLHAMMER, P. F. : Personal communication, 94. INNES, I. R., and NICKERSON, M.: Atropine, 1976. scopalamine, and related antimuscarinic drugs, in SCHOENFELD, L., CARRION, H. M., and POLITANO, Goodman, L. S., and Gilman, A., Eds., ibid.,25 pp. V. A.: Erectile impotence: complication of external 514-532. sphincterotomy, Urology 4: 681 (1974). 95. DIOKNO, A. C., HYNDMAN, C. W., HARDY, D. A., and LAPIDES, J.: Comparison of action of imiCOMARR, A. E.: Sexual concepts in traumatic cord and cauda equina lesions, J. Urol. 106: 375 (1971). pramine (Tofranil) and propantheline (Probanthine) on detrusor contraction, J. Urol. 107: 42 (1972). STARK, G.: Pudendal neurectomy in management 96. HEOCK, E.: Discussion, Acta Neurol. Stand. [Supof neurogenic bladder in myelomeningocele, Arch. ~1.1 42: 180 (1966). Dis. Child. 44: 698 (1969). MULHOLLAND, S. G., YALLA, S. V., RAEZER, D. 97. COLE, A. T., and FRIED, F. A.: Favorable experiM., and DUCKETT, J. W., JR.: Primary external ences with imipramine in the treatment of urethral sphincter hyperkinesia in a boy, Urology 4: neurogenic bladder, J. Urol. 107: 44 (1972). 577 (1974). 98. RAEZER, D. M., BENSON, G. S., WEIN, A. J., and Ross, J. C., and DAMANSKI, M.: Pudendal neurecDUCKETT, J. W., JR.: The functional approach to tomy in the treatment of the bladder in spinal injury, the management of the pediatric neuropathic bladder - a clinical study. Submitted for publication. J. Urol. 25: 45 (1953). UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 of the uninhibited bladder by selective sacral neurecR. E. G.: Imipramine hydrochloride tomy, Br. J. Urol. 46: 639 (1974). and enuresis, Am. J. Psychiat. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 117: 551 (1960). 116. SCOTT, F. B., BRADLEY, W. E., and TIMM, G. 100. MILLER, P., CHAMPELLI, J., and DINELLO, F.: A W.: Treatment of urinary incontinence by an imdouble blind study of imipramine in the treatment of plantable prosthetic sphincter, J. Urol. 112: 75 enuretic schoolchildren, Am. J. Dis. Child. 115: 17 (1974). (1968). 117. HALD, T., BYSTROhl, J,, and ALFTHAN, 0.: Treat101. BYCK, R.: Drugs and the treatment of psychiatric ment of urinary incontinence by the Scott-Bradleydisorders, in Goodman, L. S., and Gihnan, A., Eds., zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDC Timm artificial sphincter, Urol. Res. 3: 133 (1975). ibid. ,25 pp. 152-200. 118. CALDWELL, K. P. S.: The electrical control of D. T., LAFERTE, R. O., and MAHONEY, 102. MAHONEY, sphincter incompetence, Lancet 2: 174 (1963). J. E.: Observations on sphincter augmenting effect 119. MERRILL, D. C., CONWAY, C. C., and DEWOLF, of imipramine in children with urinary incontinence, W.: Urinary incontinence: treatment with electrical Urology 1: 317 (1973). stimulation of the pelvic floor, Urology 5: 67 (1975). 103. BENSON, G. S., SARSHIK, S. A., RAEZER, D. M., and 120. TARABULCY, E., MORALES, P. A., and SULLIVAN, J. WEIS, A. J.: Comparative effects and mechanisms F.: Vesicoureteral reflux in paraplegics: results of of action of atropine, propantheline, flavoxate, and various forms of management, Paraplegia 10: 44 imipramine on bladder muscle contractility. Submit(1972). ted for publication. 121. REECE, R. W., and HACKLER, R. H.: Ves104. INNES, I. R., and NICKERSON, M.: Norepinephrine, icoureteroplasty in the paraplegic: long-term followepinephrine, and the sympathomimetic amines, in up in 77 patients, J. Urol. 113: 474 (1975). Goodman, L. S., and Gilman, A., Eds., ibid. ,25 pp. 122. WOODRUFF, M. W., and OBERHEIM, W. S.: Uri477-513. nary diversion in the treatment of neurogenic blad105. DIOKNO, A. C., and TAUB, M.: Ephedrine in der, Urol. Clin. North Am. 1: 99 (1974). treatment of urinary incontinence, Urology 5: 624 123. KOZIOL, I., and HACKLER, R. H.: Cutaneous (1975). ureteroileostomy in spinal cord-injured patient: a 106. KOHLER, R. P., and MORALES, P. A.: Cystometric 15-year experience, J. Urol. 114: 709 (1975). evaluation of flavoxate hydrochloride in normal and 124. BRICKER, E. M.: Bladder substitution after pelvic neurogenic bladder, J. Urol. 100: 729 (1968). 107. BHADLEY, D. U., and CAZORT, R. J.: Relief of evisceration, Surg. Clin. North .4m. 30: 1511 (1950). 125. MURPHY, J. J., and SCHOENBERG, H. W.: Survey bladder spasm by flavoxate: a comparative study, J, Clin. Pharmacol. 10: 65 (1970). of long term results of urinary diversion, Br. J. Urol. 39: 700 (1967). 108. LISH, P. M., LABUDDE, J. A., PETERS, E. L., and an126. SCHMIDT, J. D., HAWTREY, C. E., FLOCKS, R. H., ROBBINS, S. I.: Oxybutynin - a musculotropic tispasmodic drug with moderate anticholinergic acand CULP, D. A.: Complications, results and problems of ileal conduit diversion, J. Ural. 109: 210 zyxwvutsrqpon 156:467 (1965). tion, Arch. Int. Pharmacodyn. (1973). 109. DIOKR’O, A. C., and LAPIDES, J.: Oxybutynin: a new drug with analgesic and anticholinergic proper127. GREGORY, J. G., GURSAHANI, M., and SCHOENFive-year radiographic review of ileal ties, J. Urol. 108: 307 (1972). BERG, H. W.: 110. KIESSWETTER, H., and SCHOBER, W.: Lioresal in conduits, ibid. 112: 327 (1974). the treatment of neurogenic bladder dysfunction, urinary in128. MOGG, R. A.: Treatment of neurogenic Urol. Int. 30: 63 (1975). continence using colonic conduit, Br. J, Urol. 37: 681 111. MISAK, S. J., BUNTS, R. C., ULMER, J. L., and (1965). 129. IDEM: Urinary diversion using the colonic conduit, zyxwvutsrqpon EAGLES, W. M.: Nerve interruption procedures in ibid. 39: 687 (1967). the urologic management of paraplegic patients, J. 130. KELALIS, P. P.: Urinary diversion in children by Urol. 88: 392 (1962). the sigmoid conduit, J. Ural. 112: 666 (1974). 112. MEIROWSKY, A. M., SCHEIBERT, C. D., and HIN131. MORALES, P., and GOLIMBU, M. : Colonic urinary diCHEB, T. R. : Studies on the reflex arc in paraplegia, version: 10 years of experience, I. J. Neurosurg. 7: 33 (1950). ibid. 113:302 (1975). 132. SKINNER, D. G., GOTTESMAN, J. E., and RICHIE, J, 113. HEIMBURGER, R. F., FREEMAN, L. W., and WILDE, P.: The isolated sigmoid segment: its value in temN. J.: Sacral nerve innervation of the human bladporary urinary diversion and reconstruction, ihid. der, ibid. 5: 154 (1948). 113: 614 (1975). 114. ROCKSWOLD, G. L., BRADLEY, W. E., and CHOU, S. 133. SCHWARZ, G. R., and JEFFS, R. D.: Ileal conduit N. : Differential sacral rhizotomy in the treatment of diversion in children: computer analysis of followup neurogenic bladder dysfunction, ibid. 38: 748 (1973). 115. TORRENS, W. J., and GRIFFITH, H. B.: The control from 2 to 16 years, ibid. 114: 285 (1975). 99. MACLEA~V, UROLOGY / NOVEMBER 1976 / VOLUME VIII, NUMBER 5 443