Case report-bladder voiding stimulation techneque cause vecirorueteral reflux
Wei-Hsuan Huang, Chieh-Lung Chou, Chao-Hsiang Chang
Department of Urology, China Medical University Hospital, Taichung, Taiwan
Neurogenic bladder is a dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of micturition. Methods to improve bladder emptying consist of two main strategies: to increase intravesical pressure and to decrease outlet resistance. Textbook also mentioned that using trigger technique such as tapping or scratching the skin above the pubis or external genitalia, pulling the skin or hair of the pubis, scrotum, or thigh; squeezing the clitoris; or by digital rectal stimulation, could induce bladder reflexively to empty. Our patient had use this kind of technique but cause VU reflux and hydronephrosis.
A 62-year-old male who was falling down from a tree(3m height) developed T7 and T8 burst fracture. T7 complete paraplegia with neurogenic bladder and neurogenic bowel were noted after surgery. CISC was arranged for him. He had ICP 4 times/day plus suprapubic tapping and Crede manuvar. and decreased residual urine amount after TURP+TUI. He had regular OPD follow up and residual urine all around 100ml and renal echo found no hydronephrosis. We had suggested him not to tapping and had increase ICP frequency and add Anti-M drug.
However, Recurrent UTI and follow up renal echo found Bil. Hydronephrosis, and Left hydroureter (As Figure 1) recently. We arrange VUDS for examination. VUDS (As Figure 2) found bladder capacity was about 500ml but still no voiding sensation. Suprapubic tapping stimulation was given during VUDS and found detrusor muscle contraction along with left VU reflux. No detrusor overactivity, No obstruction, No Stress urinary incontinence were found. We had suggested him to increase CISC frequency and not tapping for voiding. Now patient condition was stable and CISD for about 500ml.
Xiao et al. had found the reflex route that the L7 motor axons, which regenerate into the S1 spinal nerve terminate in the pelvic ganglia and synapse with bladder ganglion cells or that they project into the bladder and communicate directly with the detrusor smooth muscle. In this case, trigger technique stimulated the bladder detrusor muscle contraction, but bladder sphincter do not open at the same time cause VU reflux. Tai et al, had mentioned when bladder volume is large, the bladder spinal reflex can drive the detrusor to generate very high intravesical pressures necessary for voiding. However, at the same time the bladder afferents can also drive the pudendal efferents to contract the external urethra sphincter, which blocks voiding. J.J. Wyndaele et al had follow up 105 SCI patients, Vesico-ureteral reflux was demonstrated in four of the 18 patients who used trigger technique. S.J. Foley et al considered the used of reflex voiding by suprapubic voiding is discourage. Clare J. Fowler et al had mentioned that the SCI pt, just like severe " dysfunctional voiding " will damage UB and upper urinary tract. James Middleton also had mention that using the reflex voiding will cause some late complication including vesico-reteric reflux, hydronephrosis, pyolonephritis and deterioration of renal function. As this case, we do not suggest to using suprapubic trigger technique. Sphincter do not activate at the same time while detrusor muscle activity increased anc cause high intravesicle pressure. VU reflux was found and longterm prognosis is not good due to frequency VU reflux and recurrent APN. We suggested this patient should stop using detrusor stimulation technique and increase intermittent clean self-catheterization frequency.
In this case, detrusor stimulation technique do really activate the detursor muscle activity but cause VU reflux. Detrusor stimulation technique do really activate the detursor activity in some kinds of SCI patient but suitable or not need a larger number of cases with VUDS survey. As our opinion, SCI patient should increase the frequency of intermittent clean self catheterization and avoided using trigger technique.