The Journal of The American Paraplegia Society
ISSN: 0195-2307 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yscm19
Balloon Dilatation of the External Urethral Sphincter: A Case Study Patrick Werbrouck, Luc Baert, Joseph E. Binard, Rie K. Chiou & Heinz Van Poppel To cite this article: Patrick Werbrouck, Luc Baert, Joseph E. Binard, Rie K. Chiou & Heinz Van Poppel (1990) Balloon Dilatation of the External Urethral Sphincter: A Case Study, The Journal of The American Paraplegia Society, 13:2, 13-14, DOI: 10.1080/01952307.1990.11735809 To link to this article: http://dx.doi.org/10.1080/01952307.1990.11735809
Published online: 02 Jun 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yscm19 Download by: [Australian Catholic University]
Date: 01 September 2017, At: 14:29
consistency of the fecal stream and in attention to the integument (as in Case #2). Provision of colostomy ought always to include preoperative planning and teaching by an occupational therapist and an enterostomal nurse specialist.
elective fecal diversion should probably be considered before skin breakdown necessitates such action by its potential morbidity and mortality.
Downloaded by [Australian Catholic University] at 14:29 01 September 2017
REFERENCES CONCLUSIONS There are some SCI patients for whom elective fecal diversion is indicated. First, such diversion has a role to play as an adjunct to treatment of pressure sores. Second, fecal incontinence as well as occasional prolonged evacuation are sometimes indications. Finally, CE should be considered in those patients for whom medical management has been unsuccessful or vocation/avocation are impaired as a result of unsuccessful ARE (Case# 1). As noted, there may be neurochemical processes within the viscera that play a role in "chronic constipation," but these avenues of dysfunction require further investigation. The need for colostomy may be regarded as a concession to failed self-care and surveillance of the integument; however,
1. Frisbie J, TunC, Nguyen C. Effect of enterostomy on quality of life in spinal cord injured patents. JAm Para Soc 1986;9:3-5. 2. Romano JA, Saltzstein RJ. The value of colostomy in the treatment and care of spinal cord injured patients. Abstr, In: Plastic and Reconstructive Surgery, 27th Annual Senior Residents' Conference, March 1988. 3. Koch TR, et a!. Idiopathic chronic constipation is associated with decreased colonic vasoactive intestinal peptide. Gastroenterology 1988;94:300-31 0. 4. Koch TR, Roddy DR, Go VLW. Abnormalities of fasting serum concentrations of peptide YY in the idiopathic inflammatory bowel diseases. Am J Gastroenterol 1987;82:321-326.
BALLOON DILATATION OF THE EXTERNAL URETHRAL SPHINCTER: A Case Study *Patrick Werbrouck, M.D.,*Luc Baert, M.D., **Joseph E. Binard, M.D., FRCS(C), **Rie K. Chiou, M.D., and *Heinz Van Poppel, M. D. ABSTRACT A new and simple endoscopic treatment procedure of external urethral sphincters is described. The external urethral sphincter was dilated with a balloon catheter 25mm in diameter in a multiple sclerosis patient; the sphincter spasticity made intermittent catheterization impossible. Post dilatation, the resistance to catheterization competely disappeared and the urethral pressure profile showed a dramatic fall in sphincteric pressure. This fall in sphincteric pressure has remained at a normal post dilatation level at the time of submission of this article (7 months). (J Am Paraplegia Soc 1990;13:13-14) Key Words: balloon catheter; external urethral sphincters; sphincteric pressure
INTRODUCTION Transurethral sphincterotomy is a commonly performed surgical procedure in the treatment of bladder outlet obstruction as found in detrusor external sphincter dyssynergia.U This syndrome affects many patients with traumatic lesions of the spinal cord or neurologic disorders such as multiple sclerosis. *From the Department of Urology, University Hospital, Katholieke Universiteit, Leuven, Belgium. **Department of Surgery, Section of Urology, VA Medical Center, Washington, D. C. Supported by a grant from the Eastern Paralyzed Veterans Association.
Apri/1990
In a study of 160 patients with proven neurogenic bladder caused by multiple sclerosis, at least 22 patients had an overactive external urethral sphincter. 3 Sphincterotomy, however, has significant morbidity including bleeding and sepsis, and its efficacy is not always achieved. In some patients multiple surgeries are required. Since transurethral balloon dilatation for obstructive benign prostatic hyperplasia proved successful, 4 the efficacy of balloon dilatation in detrusor sphincteric dyssynergia was evaluated.
JAm Paraplegia Soc Vo/13 No 2
13
Downloaded by [Australian Catholic University] at 14:29 01 September 2017
................-....: .: . . · _________... ············· ~
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Figure 1 Urethral pressure profile before (--) and after ( ... ••) balloon dilatation of the spastic external sphincter.
CASE REPORT A 36 year-old male patient suffering from multiple sclerosis for over 13 years, was treated with intermittent catheterization for several years; the ICP was required because of overflow incontinence due to spacicity of the external sphincter and detrusor hypo/areflexia. Despite high dosages of anti-spasmodic agents (baclofen and diazepam), sphincter spasticity increased to such a degree that catheterization became totally impossible. The patient had satisfactory erections but no ejaculation. Urodynamic studies revealed a hypoactive bladder and the urethral pressure profile showed an extremely high pressure up to 200 em H20 at the level of external sphincter (figl.). Urethrocystography and endoscopy confirmed the spasticity of the external sphincter. A dilation of the external sphincter was performed under general anesthesia using a 75 French balloon. The balloon was placed at the level of the external sphincter under direct urethorscopy. The tendency of the balloon to slip into the bulbous urethra was prevented by the usage of the longer (35mm) American Surgical Intervention balloon which also actually dilated the prostatic urethra. After the dilatation, an 18 French Foley cather was inserted with ease and was left indwelling for 48 hours. Thereafter, intermittent catherterization program could be reinsituted and remained extrememly easy to accomplish. Several postoperative urethral pressure profiles were per-
14
formed. They showed a dramatic fall in sphincteric pressure, from a range preoperatively of 170 - 200 em H20 to a range of 20-40 em H20 post dilatation. A slight lowering of the pressure profile at the level of the prostatic urethra was also observed. Urethrography showed a wide open external sphincter. There was no incontinence but micurition was still impossible because of detrusor hypoactivity. The patient observed no changes in the quality and frequency of erections.
DISCUSSION The experience reported here demonstrates a new and simple treatment for spastic external urethral sphincters. A larger sampling certainly will be necessary to confirm these findings to demonstrate long-term efficacy and to determine relative complication rates. REFERENCES I. Madersbacher i-1, Scott FB. The twelve o'clock sphincterotomy technique, indications, results. Paraplegia 1976; 13:261-267. 2. Silver, JR. Role of outflow surgery in the rehabilitation of male paraplegic patients. Int Rehabil Med 1983;5: 143-148. 3. Van Poppet H, Vereecken RL, Leruitte A. Neuro-muscular dysfunction of the lower urinary tract in multiple sclerosis. Paraplegia 1983;21 :374-379. 4. Reddy PK, WassermanN. Castaneda-Zuniga WR. Balloon dilatation of the prostate for treatment of benign hyperplasia. Urol Clin NA 1988; 15:529-535.
1 Am Paraplegia Soc Vo/13 No 2
Apri/1990
ISSN: 0195-2307 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yscm19
Balloon Dilatation of the External Urethral Sphincter: A Case Study Patrick Werbrouck, Luc Baert, Joseph E. Binard, Rie K. Chiou & Heinz Van Poppel To cite this article: Patrick Werbrouck, Luc Baert, Joseph E. Binard, Rie K. Chiou & Heinz Van Poppel (1990) Balloon Dilatation of the External Urethral Sphincter: A Case Study, The Journal of The American Paraplegia Society, 13:2, 13-14, DOI: 10.1080/01952307.1990.11735809 To link to this article: http://dx.doi.org/10.1080/01952307.1990.11735809
Published online: 02 Jun 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yscm19 Download by: [Australian Catholic University]
Date: 01 September 2017, At: 14:29
consistency of the fecal stream and in attention to the integument (as in Case #2). Provision of colostomy ought always to include preoperative planning and teaching by an occupational therapist and an enterostomal nurse specialist.
elective fecal diversion should probably be considered before skin breakdown necessitates such action by its potential morbidity and mortality.
Downloaded by [Australian Catholic University] at 14:29 01 September 2017
REFERENCES CONCLUSIONS There are some SCI patients for whom elective fecal diversion is indicated. First, such diversion has a role to play as an adjunct to treatment of pressure sores. Second, fecal incontinence as well as occasional prolonged evacuation are sometimes indications. Finally, CE should be considered in those patients for whom medical management has been unsuccessful or vocation/avocation are impaired as a result of unsuccessful ARE (Case# 1). As noted, there may be neurochemical processes within the viscera that play a role in "chronic constipation," but these avenues of dysfunction require further investigation. The need for colostomy may be regarded as a concession to failed self-care and surveillance of the integument; however,
1. Frisbie J, TunC, Nguyen C. Effect of enterostomy on quality of life in spinal cord injured patents. JAm Para Soc 1986;9:3-5. 2. Romano JA, Saltzstein RJ. The value of colostomy in the treatment and care of spinal cord injured patients. Abstr, In: Plastic and Reconstructive Surgery, 27th Annual Senior Residents' Conference, March 1988. 3. Koch TR, et a!. Idiopathic chronic constipation is associated with decreased colonic vasoactive intestinal peptide. Gastroenterology 1988;94:300-31 0. 4. Koch TR, Roddy DR, Go VLW. Abnormalities of fasting serum concentrations of peptide YY in the idiopathic inflammatory bowel diseases. Am J Gastroenterol 1987;82:321-326.
BALLOON DILATATION OF THE EXTERNAL URETHRAL SPHINCTER: A Case Study *Patrick Werbrouck, M.D.,*Luc Baert, M.D., **Joseph E. Binard, M.D., FRCS(C), **Rie K. Chiou, M.D., and *Heinz Van Poppel, M. D. ABSTRACT A new and simple endoscopic treatment procedure of external urethral sphincters is described. The external urethral sphincter was dilated with a balloon catheter 25mm in diameter in a multiple sclerosis patient; the sphincter spasticity made intermittent catheterization impossible. Post dilatation, the resistance to catheterization competely disappeared and the urethral pressure profile showed a dramatic fall in sphincteric pressure. This fall in sphincteric pressure has remained at a normal post dilatation level at the time of submission of this article (7 months). (J Am Paraplegia Soc 1990;13:13-14) Key Words: balloon catheter; external urethral sphincters; sphincteric pressure
INTRODUCTION Transurethral sphincterotomy is a commonly performed surgical procedure in the treatment of bladder outlet obstruction as found in detrusor external sphincter dyssynergia.U This syndrome affects many patients with traumatic lesions of the spinal cord or neurologic disorders such as multiple sclerosis. *From the Department of Urology, University Hospital, Katholieke Universiteit, Leuven, Belgium. **Department of Surgery, Section of Urology, VA Medical Center, Washington, D. C. Supported by a grant from the Eastern Paralyzed Veterans Association.
Apri/1990
In a study of 160 patients with proven neurogenic bladder caused by multiple sclerosis, at least 22 patients had an overactive external urethral sphincter. 3 Sphincterotomy, however, has significant morbidity including bleeding and sepsis, and its efficacy is not always achieved. In some patients multiple surgeries are required. Since transurethral balloon dilatation for obstructive benign prostatic hyperplasia proved successful, 4 the efficacy of balloon dilatation in detrusor sphincteric dyssynergia was evaluated.
JAm Paraplegia Soc Vo/13 No 2
13
Downloaded by [Australian Catholic University] at 14:29 01 September 2017
................-....: .: . . · _________... ············· ~
------
Figure 1 Urethral pressure profile before (--) and after ( ... ••) balloon dilatation of the spastic external sphincter.
CASE REPORT A 36 year-old male patient suffering from multiple sclerosis for over 13 years, was treated with intermittent catheterization for several years; the ICP was required because of overflow incontinence due to spacicity of the external sphincter and detrusor hypo/areflexia. Despite high dosages of anti-spasmodic agents (baclofen and diazepam), sphincter spasticity increased to such a degree that catheterization became totally impossible. The patient had satisfactory erections but no ejaculation. Urodynamic studies revealed a hypoactive bladder and the urethral pressure profile showed an extremely high pressure up to 200 em H20 at the level of external sphincter (figl.). Urethrocystography and endoscopy confirmed the spasticity of the external sphincter. A dilation of the external sphincter was performed under general anesthesia using a 75 French balloon. The balloon was placed at the level of the external sphincter under direct urethorscopy. The tendency of the balloon to slip into the bulbous urethra was prevented by the usage of the longer (35mm) American Surgical Intervention balloon which also actually dilated the prostatic urethra. After the dilatation, an 18 French Foley cather was inserted with ease and was left indwelling for 48 hours. Thereafter, intermittent catherterization program could be reinsituted and remained extrememly easy to accomplish. Several postoperative urethral pressure profiles were per-
14
formed. They showed a dramatic fall in sphincteric pressure, from a range preoperatively of 170 - 200 em H20 to a range of 20-40 em H20 post dilatation. A slight lowering of the pressure profile at the level of the prostatic urethra was also observed. Urethrography showed a wide open external sphincter. There was no incontinence but micurition was still impossible because of detrusor hypoactivity. The patient observed no changes in the quality and frequency of erections.
DISCUSSION The experience reported here demonstrates a new and simple treatment for spastic external urethral sphincters. A larger sampling certainly will be necessary to confirm these findings to demonstrate long-term efficacy and to determine relative complication rates. REFERENCES I. Madersbacher i-1, Scott FB. The twelve o'clock sphincterotomy technique, indications, results. Paraplegia 1976; 13:261-267. 2. Silver, JR. Role of outflow surgery in the rehabilitation of male paraplegic patients. Int Rehabil Med 1983;5: 143-148. 3. Van Poppet H, Vereecken RL, Leruitte A. Neuro-muscular dysfunction of the lower urinary tract in multiple sclerosis. Paraplegia 1983;21 :374-379. 4. Reddy PK, WassermanN. Castaneda-Zuniga WR. Balloon dilatation of the prostate for treatment of benign hyperplasia. Urol Clin NA 1988; 15:529-535.
1 Am Paraplegia Soc Vo/13 No 2
Apri/1990
