460

Practical Urology: EssEntial PrinciPlEs and PracticE

study reported that up to 37% had DSD implying

DO with and without DSD often develop.

spinal involvement.34 Up to 16% may show DA.

Thoracic disks although less frequent than at

UI can often be preceded with an intense

cervical or lumbosacral levels can cause voiding

urgency. Rarely, micturition itself can trigger a

complaints in a quarter to a third of patients.

seizure. It should also be noted that antiepilep-

The spinal cord terminates at the level of mid L1

tics such as gabapentin have been associated

vertebral body in adults. Most disk prolapses

with UI.35

occur at either L4/L5 or L5/S1. But at least 75%

nerve compression is required to trigger symp-

Encephalitis/Progressive Multifocal

toms and bladder dysfunction.39 Although clas-

sically DA is reported in a quarter of patients on

Leukoencephalopathy (PML)

UDS, neurogenic DO can occur.40 Areflexia

PML is an infectious demyelinating disorder of

results from posteriolateral disk protrusion

which can injure afferent input necessary to

the brain of viral origin occurring in immuno-

trigger a micturition reflex. Eventually, bladder

suppressed patients such as those with AIDS.

overdistension can cause changes in compliance

Isolated reports exist of UI and OAB.

and detrusor contractility. DO is likely due to

nerve root irritation. Although most patients

Tumors

with cauda equina syndrome exhibit normal

bladder compliance, up to 28% have reduced

UI can develop with frontal lobe tumors along

compliance.41

Treatment of herniated disks can improve blad-

with indifference and disinhibition. OAB had

der function. The most important predictor of

been found in 14% of frontal lobe tumors mani-

recovery of bladder function is absence of peria-

festing with behavioral changes.36

nal anesthesia though cauda equina syndrome

can exist without sacral anesthesia. If detrusor

Psychiatric Disorders

areflexia is found preoperatively, chances of

postoperative recovery of bladder function is

Recent epidemiologic studies implicate depres-

less even if perianal sensation returns.

sion and anxiety in the pathogenesis of OAB

Regardless, recovery of bladder contractions

possibly sharing a similar neurochemical back-

may take years with only a third in retention

ground. Often LUTS occurs years after psychiat-

resuming voiding.

ric symptoms. Urodynamics may reveal DO and

a positive ice water test suggestive of C fiber-

mediated reflex micturition.37 Treatment of

Spinal Cord Injury (SCI)

these disorders fails to eradicate LUTS; con-

versely, successful treatment of LUTS does not

The level of SCI provides a guide as to findings

universally relieve depression and anxiety.

on UDS. Injuries rostral to the SPN are often

Interestingly, the tricyclic antidepressants and

associated with DSD. Injury at the thoracic spine

duloxetine which raise CNS levels of 5-HT and

corresponding to the sacral center may lead to

NE have been shown to have some efficacy for

DA with an open outlet leading to SUI.

OAB or urge UI. Lithium used to treat manic

Thoracolumbar injury may also lead to detrusor

depression can cause diabetes insipidus and uri-

internal sphincter dyssynergia diagnosed by a

nary frequency.38

detrusor contracting against a closed bladder

neck on video UDS. Patients with a hostile blad-

der merit frequent renal ultrasounds (e.g., 3–6

Spinal Lesions and Pathology

months).

Patients with SCI at or above T6 may develop

Intervertebral Disk Prolapse

autonomic dysreflexia (AD) characterized by

hypertension, sweating, and bradycardia. Imm-

Lumbosacral disk herniation is common and

ediate treatment is to empty the bladder. Phar-

macologic management with nifedipine (bite and

can lead to neurogenic bladder and litigation.

swallow), nitroglycerine ointment above the

With cervical spine disk herniations, neurogenic

lesion, or intravenous sodium nitroprusside is