URODYNAMIC EVALUATION AFTER ABDOMINAL-PERINEAL RESECTION AND LUMBAR INTERVERTEBRAL DISK HERNIATION EDWARD J . McGUIRE, M .D . From the Department of Surgery, Section of Urology, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT - Thirteen patients with neuropathic vesical dysfunction resulting from intervertebral disk herniation or abdominal-perineal resection have been evaluated with a urodynamic technique . Urinary sphincter weakness was common, and it appears to be responsible for poor results in patients treated by transurethral resection .
Transurethral resection of the bladder neck and prostate is an accepted method of treatment of urinary retention resulting from neuropathic vesical dysfunction . 1 '2 In patients with difficulty in voiding after lumbar intervertebral disk herniation or abdominal-perineal resection for carcinoma of the rectum, benign prostatic hyperFIGURE 1 .
trophy may complicate detrusor weakness . Prostatectomy has been performed in such patients with good results . 3 However, we have recently encountered 7 patients in whom transurethral prostatic resection led to either urinary incontinence or persistent difficulty in voiding . These patients were studied with simultaneous bladder
Experimental arrangement of system .
UROLOGY / JULY 1975 / VOLUME VI, NUMBER I
6
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Plotted profile data cm H
obtained by catheter withdrawal in
and urethral pressure technique to determine the cause ofthe poor surgical result Six additional patients with urinary retention after interverte bral disk herniation or abdominal perineal resec tion were studied with the same technique Re sults in the latter group indicated that transure thral resection was inadvisable in 5 of the 6 pa tients studied Methods Urodynamic studies
A two catheter modification of the urethral pressure profile technique described by Brown and Wickham was used to assess bladder and cc per minute urethral functions A constant flow was induced with a double barreled syringe pump in two identical 8 F catheters constructed with a mm lateral perfusion aperture cm from their occluded distal tips Statham P A pressure transducers were connected to each per fusion system and recordings made on a Grass polygraph Fig Resistance to flow was initially determined with both catheters at the level ofthe pubic symphysis and arbitrarily accepted as zero base line Both catheters were then inserted into the bladder and a standard cystometrogram ob tained by filling the bladder to capacity or by detrusor contraction At intervals during bladder and cc one catheter was filling slowly withdrawn through the urethra while the other remained in the bladder Withdrawal was performed manually in cm steps with ten sec onds allowed at each step for pressure equilibra tion In this way the lateral perfusion aperture of one catheter traversed the area from the bladder neck to the urethral bulb Urethral resistance produced a characteristic and reproducible series ofpressure changes during the withdrawal which 64
normal forty year old males
were compared with the relatively constant pres sure exerted against the companion bladder catheter Figure shows plotted urethral pres sure profile data obtained on multiple determina tions in normal forty year old males The characteristics of single catheter pressure profiles have been described by Edwards and Malvern Pressure profile results with the two catheter technique are comparable to those with the single catheter technique Effective urethral length can be arbitrarily defined by this technique as that distance of urethra manifesting a higher pressure than that of bladder This value was determined by measur ing the length of the catheter withdrawn from the external urethral meatus from the onset of the first elevation of urethral pressure to the point at which urethral pressure fell below intravesical pressure In normal males this distance measured 4 to 5 cm Fig Fluoroscopic monitoring
The perfusate used in both systems was per cent diatrizoate This permitted visualization of the bladder the bulbous urethra both perfusion catheters and the perfusion aperture of the urethral profile catheter which was visible as the distal end ofa solid column ofcontrast material In patients with deficiencies of urethral spincter re sponse localization of the perfusate aperture fluoroscopically was necessary to be certain ofthe anatomic area in which pressures were being re corded Electromyographic data
Two no one inch monopolar Grass platinum needle electrodes were inserted as deeply as possible into the perineum on either side of the bulbous urethra Constant elec
UROLOGY
JULY 975
VOLUME VI NUMBER
Results of evaluation in patients with prior urologic operative procedures and in patients with no prior surgery
TABLE I
Case Number
Prestudy Status Urinary Residual cc
Procedure
Neurologic Lesion
PATIENTS WITH PRIOR UROLOGIC SURGERY
TURP TURP TURP TURP TURP TURP TURP
Lumbar disk herniation Lumbar disk herniation Lumbar disk herniation Lumbar disk herniation Abdominal perineal resection Abdominal perineal resection Abdominal perineal resection
4 5 6 7
x
5 8 6 Incontinent Incontinent Incontinent Incontinent
x x x
PATIENTS WITH No PRIOR SURGERY
6 4
Lumbar disk herniation Lumbar disk herniation Abdominal perineal resection Abdominal perineal resection Abdominal perineal resection Abdominal perineal resection
4 5 6
5 8 6
Results offunctional evaluation in patients with previous transurethral resection and in patients with no prior urologic surgery
TABLE II
Detrusor Response During Bladder Filling to ml
Case Number
Urethral Profile Response Cm H Bladder Neck Cm Cm
4 Cm
EMG Study
PATIENTS WITH PREVIOUS TRANSURETHRAL RESECTION
4* 5 6 7
None None Occasional weak contraction None Small capacity; no detrusor response None None
None None None None None
48 56 6 4
None None
5 8
Normal Normal Normal Poor Normal Poor Poor
PATIENTS WITH NO PREVIOUS UROLOGIC SURGERY
4 5 6
Weak detrusor contraction at 8 cc None None None None None
4
6
Normal
48
Poor Poor Poor Poor Normal
Incontinent
tromyographic recordings were made during all pressure measurements Simultaneous bladder and urethral pressures Following the initial profile determination and based on the data obtained in those studies and under fluoroscopic control the urethral perfusion aperture was positioned in a selected urethral
UROLOGY
JULY 975
VOLUME VI NUMBER
area during bladder filling Measurement of urethral responses to voiding efforts could then he made from a specific urethral area Results Seven patients were evaluated for poor results following transurethral resection Four of these patients were incontinent but three were unable to void satisfactorily Table I All showed poor
65
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u Soaoi~io•a•nnw FIGURE A and B Simultaneous bladder and urethral pressures in twenty seven year old man after intervertebral disk herniation and transurethral pros tatic resection Urethral profile shows activity only in area of external sphincter; with urethral perfusion aperture at this level attempt at voiding is recorded Increase in EMG activity and parallel elevation in bladder and urethral pressures also shown Open pros tatic urethra shown on radiograph 9 mm taken dur ing voiding attempt Urethral perfusion aperture positioned just at area of urethral narrowing BN = bladder neck; PU = bladder neck to 5 cm from bladder neck; S = 5 to 4 cm from bladder neck
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a r∎∎r ~u~wr~rr∎d∎wow∎rrww6es®w~ := ∎ ~® e fw∎ ~∎C∎∎~iE® A and B Urethral and bladder pressures EMG and urethral profile of patient incontinent after No urethral profile abdominal perineal resection for rectal carcinoma and transurethral prostatic resection X squeeze increase attempt to hold urine voluntarily are isobaric; during response shown; bladder and urethra shown in perineal muscular activity which is not reflected in urethral pressure Free urinary leakage shown on 9 mm film taken with patient in upright position BN = to 5 cm M U = 5 to 5 cm and SP = 5 to 5 cm from bladder neck FIGURE 4
detrusor function and the onset of the urethral profile response did not occur at the bladder neck but rather at apoint to cm distal to the bladder neck The bladder and proximal to cm of urethra appeared to act as a single isobaric chamber Fluoroscopy demonstrated an incom
66
petent bladder neck and prostatic urethra The results ofthe functional evaluation of detrusor and sphincter function in these patients are given in Table II Patients with persistent difficulty in voiding after transurethral resection preserved profile
UROLOGY
JULY 975
VOLUME VI NUMBER I
A and B Bladder and urethral pres sures and EMG in patient unable to void satisfactorly after lumbar disk herniation Urethral profile shows normal response in both prostatic and membranous urethra Perfusion aperture replaced in membranous urethra during attempts to hold urine voluntarily squeeze Appropriate increase shown in membranous urethral pressure indicating competence of voluntary sphincter Competent bladder neck shown in 9 mm film BN = to 5 cm from bladder neck ; PU prostatic urethra 5 to 5 cm from bladder neck ; MU = membranous urethra 5 to 4 cm from bladder neck; BU = bulbous urethra FIGURE 5
A
responses in area of urethra from to 5 cm from the bladder neck The mean effective urethral length in these patients was cm approximately half that seen in normals The preservation of profile responses was associated with a normal
UROLOGY
JULY
975
VOLUME V[ NUMBER
perineal electromyographic recording Attempts to hold urine voluntarily resulted in an elevated urethral pressure with a concomitant increase in electromyographic activity In these patients voiding was accomplished by straining; during
67
these efforts urethral resistance rose in associ ation with an increase in perineal floor elec tromyographic activity resulting in a poor inter mittent urinary stream with a large residual urine volume The urethral pressure rise in association with the Valsalva maneuver did not appear to be true external sphincter spasm but rather an ap propriate muscular contraction of the perineal floor as a part of the effort to increase intra abdominal pressure Fig These patients were treated with an external sphincterotomy In patient severe incontinence resulted which im proved after ten weeks and all now have a good result and are voiding without difficulty with no residual urine The 4 patients who were incontinent after transurethral resection showed no urethral profile response from the bladder neck to the bulbous urethra Three ofthese patients had poor perineal floor electromyographic activity proba bly as a result of a primary neurologic injury However I patient preserved normal perineal floor electromyographic activity but this was not reflected in membranous urethral resistance It appears to be due to an injury to the membranous urethra at the time oftransurethral resection with resulting scarring and rigidity Figure 4 is a pres sure tracing from this patient with a 9 mm radiographic exposure Two of the incontinent patients were treated with a Kaufman silica gel incontinence prosthesis and I patient underwent construction of a neoprostatic urethra from an anterior bladder flap One patient has been conti nent eight months with a prosthesis but the others have persistent incontinence Patients studied prior to urologic surgery all had urinary retention Table I The results of detrusor and urethral sphincter evaluation of these patients are given in Table II Patient preserved marginal detrusor function and dem onstrated both a competent bladder neck and normal membranous urethral function Fig 5 He underwent a transurethral resection with a good result This was the sole patient who dem onstrated normal prostatic and distal urethral 4 and 5 showed sphincter function Patients no detrusor function no urethral profile re sponse and no change_ in urethral pressure with attempts to hold urine voluntarily Perineal EMG activity was poor All of these patients had under gone abdominal perineal resection and were in continent in the standing position but tolerated large bladder volumes when in supine position Figure 6 is a bladder and urethral pressure tracing in one ofthese patients three weeks after abdomi
68
nal perineal resection A preoperative urody namic evaluation had been performed in this patient Figure 7 shows urethral profiles obtained be fore and after abdominal perineal resection and after treatment with ephedrine Two of these pa tients were treated with ephedrine with im mediate improvement in urinary control but two were not treated In the latter urinary control has slowly improved but both still suffer from stress urinary incontinence Patient 6 had urinary retention after removal of a herniated lumbar disk and showed preservation of proximal urethral profile responses and in creased membranous urethral pressure on strain ing to void He underwent an external sphinc terotomy with a good result ; he is continent voids by straining and has no residual urine Comment Urinary retention in patients following abdom inal perineal resection or lumbar intervertebral disk herniation is not always accompanied by in creased outlet resistance Urinary sphincter deficiencies may occur in conjunction with de trusor failure Detrusor dysfunction may mask incontinence since these patients when in supine position commonly tolerate large bladder vol umes without leakage Thus incontinence which existed prior to urologic surgery may be accepted as a result of surgery unless these patients are in the standing position when evaluated Three types of sphincter weakness appeared in the group of patients reported : isolated defi ciency ofprofile response in the bladder neck and first to cm of urethra; isolated deficiency of the skeletal muscular component of urethral re sistance manifested by poor perineal floor EMG activity and diminished profile responses in the area from to 5 cm from the bladder neck; and absence of any measurable urethral sphincter ac tivity which appeared to be a combination of the first two conditions Urethral smooth muscle is responsive to sym pathetic stimulation and urethral smooth muscle tone may be partially under sympathetic nervous control The findings in these patients appear to he explainable in the light ofthis concept of urethral function The patients with lumbar intervertebral disk herniation preserved proximal urethral pro file responses prior to transurethral resection This would be expected since the hypogastrie plexus would not be injured by a lumbar disk
UROLOGY
I
JULY 975
VOLUME VI NUMBER
FIGURE 6 Bladder and urethral pressures with perineal EMG in patient incontinent after abdominal perineal resection No effective urethral response shown; poor EMG activity Free urinary leakage shown on 9 mm film taken with patient in upright position BN = to 5 em from anatomic bladder neck seen fluoroscopically ; PU = 5 to cm and S = to 4 5 cm from bladder neck ; BU = bulbous urethra; PU = aperture at 5 cm
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JULY 975
VOLUME VI
NUMBER I
tion of membranous urethral function and ab sence of detrusor activity a transurethral resec tion did not result in resumption of adequate voiding In these patients voiding by straining was impeded by an increase in urethral resistance
69
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which appeared to be due to increased muscular activity of the pelvic floor during the Valsalva maneuver External urethral sphincterotomy seems to be the treatment of choice in such pa tients but incontinence is likely to result if a prior transurethral resection has been performed Ad ditionally some patients with lumbar interver tebral disk herniation who preserve proximal urethral resistance but not skeletal muscular function became incontinent after transurethral resection since urethral smooth muscle function was the only remaining component of urethral resistance It seems preferable to treat these pa tients with intermittent self catheterization or administration of phenoxybenzamine to provide a reversible decrease in proximal urethral resis tance 6 Four patients studied following abdominal perineal resection but prior to transurethral re section showed complete failure of both smooth and skeletal muscular components of urethral re sistance Some return of urethral profile activity was seen after the administration of ephedrine and after a time urethral smooth muscular func tion appeared to improve spontaneously Such improvement has been reported by others Transurethral resection in these patients ap peared to impair permanently spontaneous re covery of urethral smooth muscular function Ad ditionally some patients preserved either skeletal or smooth muscular function after abdominal perineal resection If smooth muscular function was impaired a transurethral resection did not improve voiding ; if skeletal muscular function was impaired a transurethral resection resulted in in continence Moreover urologic evaluation prior to abdominal perineal resection was not reliable as total sphincter failure occurred in one such patient who might require prostatectomy follow ing surgery
7
An upright cystogram with urethral catheter removed which demonstrates a patulous open bladder neck is evidence that a transurethral re section is not likely to be beneficial In the ab sence of this finding that is with a competent bladder neck a simple pressure profile as de scribed by Edwards and Thomas 9 can be per formed at the bedside to evaluate membranous urethral function Urethral pressure should be active over a 4 cm length with a brisk pressure rise in the segment between cm and 4 cm from the bladder neck when the patient attempts to hold urine voluntarily If no membranous ure thral function is measurable a transurethral re section should be avoided since incontinence is likely to result 789 Howard Avenue New Haven Connecticut 65 4 DR M C GUIRE References
4 5 6 7 8 9
COMARU A E : Transurethral vesical neck resection ; an adjunct in the management of the neurogenic bladder J Urol 7 : 849 954 BRAASCH W F and THOMPSON G J : Treatment of the atone bladder Surg Gynec Obstet 6 : 79 9 5 LAPIDES J : Urologic complications of abdominal 974 perineal surgery Contemp Surg 5 : 8 BROWN M and WICKHAM J E A : The urethral 969 pressure profile Br J Urol 4 : EDWARDS L and MALVERN J : The urethral pressure profile ibid 46 ; 5 974 KRANE R J and OLSSON C A : Phenoxybenzamine : 65 in neurogenic bladder dysfunction J Urol 97 KLEEMAN F J ; The physiology of the internal urinary sphincter ibid 4 : 549 97 GLASS R L and SPRATn J S : Urinary complications ofabdominal perineal resection in men Am Surgeon 4 : 8 968 EDWARDS L F and THOMAS D : A simplified system for urodynamic observations Br J Urol 4 : 6 97
UROLOGY
JULY 975
VOLUME VI NUMBER
ABSTRACT - Thirteen patients with neuropathic vesical dysfunction resulting from intervertebral disk herniation or abdominal-perineal resection have been evaluated with a urodynamic technique . Urinary sphincter weakness was common, and it appears to be responsible for poor results in patients treated by transurethral resection .
Transurethral resection of the bladder neck and prostate is an accepted method of treatment of urinary retention resulting from neuropathic vesical dysfunction . 1 '2 In patients with difficulty in voiding after lumbar intervertebral disk herniation or abdominal-perineal resection for carcinoma of the rectum, benign prostatic hyperFIGURE 1 .
trophy may complicate detrusor weakness . Prostatectomy has been performed in such patients with good results . 3 However, we have recently encountered 7 patients in whom transurethral prostatic resection led to either urinary incontinence or persistent difficulty in voiding . These patients were studied with simultaneous bladder
Experimental arrangement of system .
UROLOGY / JULY 1975 / VOLUME VI, NUMBER I
6
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Plotted profile data cm H
obtained by catheter withdrawal in
and urethral pressure technique to determine the cause ofthe poor surgical result Six additional patients with urinary retention after interverte bral disk herniation or abdominal perineal resec tion were studied with the same technique Re sults in the latter group indicated that transure thral resection was inadvisable in 5 of the 6 pa tients studied Methods Urodynamic studies
A two catheter modification of the urethral pressure profile technique described by Brown and Wickham was used to assess bladder and cc per minute urethral functions A constant flow was induced with a double barreled syringe pump in two identical 8 F catheters constructed with a mm lateral perfusion aperture cm from their occluded distal tips Statham P A pressure transducers were connected to each per fusion system and recordings made on a Grass polygraph Fig Resistance to flow was initially determined with both catheters at the level ofthe pubic symphysis and arbitrarily accepted as zero base line Both catheters were then inserted into the bladder and a standard cystometrogram ob tained by filling the bladder to capacity or by detrusor contraction At intervals during bladder and cc one catheter was filling slowly withdrawn through the urethra while the other remained in the bladder Withdrawal was performed manually in cm steps with ten sec onds allowed at each step for pressure equilibra tion In this way the lateral perfusion aperture of one catheter traversed the area from the bladder neck to the urethral bulb Urethral resistance produced a characteristic and reproducible series ofpressure changes during the withdrawal which 64
normal forty year old males
were compared with the relatively constant pres sure exerted against the companion bladder catheter Figure shows plotted urethral pres sure profile data obtained on multiple determina tions in normal forty year old males The characteristics of single catheter pressure profiles have been described by Edwards and Malvern Pressure profile results with the two catheter technique are comparable to those with the single catheter technique Effective urethral length can be arbitrarily defined by this technique as that distance of urethra manifesting a higher pressure than that of bladder This value was determined by measur ing the length of the catheter withdrawn from the external urethral meatus from the onset of the first elevation of urethral pressure to the point at which urethral pressure fell below intravesical pressure In normal males this distance measured 4 to 5 cm Fig Fluoroscopic monitoring
The perfusate used in both systems was per cent diatrizoate This permitted visualization of the bladder the bulbous urethra both perfusion catheters and the perfusion aperture of the urethral profile catheter which was visible as the distal end ofa solid column ofcontrast material In patients with deficiencies of urethral spincter re sponse localization of the perfusate aperture fluoroscopically was necessary to be certain ofthe anatomic area in which pressures were being re corded Electromyographic data
Two no one inch monopolar Grass platinum needle electrodes were inserted as deeply as possible into the perineum on either side of the bulbous urethra Constant elec
UROLOGY
JULY 975
VOLUME VI NUMBER
Results of evaluation in patients with prior urologic operative procedures and in patients with no prior surgery
TABLE I
Case Number
Prestudy Status Urinary Residual cc
Procedure
Neurologic Lesion
PATIENTS WITH PRIOR UROLOGIC SURGERY
TURP TURP TURP TURP TURP TURP TURP
Lumbar disk herniation Lumbar disk herniation Lumbar disk herniation Lumbar disk herniation Abdominal perineal resection Abdominal perineal resection Abdominal perineal resection
4 5 6 7
x
5 8 6 Incontinent Incontinent Incontinent Incontinent
x x x
PATIENTS WITH No PRIOR SURGERY
6 4
Lumbar disk herniation Lumbar disk herniation Abdominal perineal resection Abdominal perineal resection Abdominal perineal resection Abdominal perineal resection
4 5 6
5 8 6
Results offunctional evaluation in patients with previous transurethral resection and in patients with no prior urologic surgery
TABLE II
Detrusor Response During Bladder Filling to ml
Case Number
Urethral Profile Response Cm H Bladder Neck Cm Cm
4 Cm
EMG Study
PATIENTS WITH PREVIOUS TRANSURETHRAL RESECTION
4* 5 6 7
None None Occasional weak contraction None Small capacity; no detrusor response None None
None None None None None
48 56 6 4
None None
5 8
Normal Normal Normal Poor Normal Poor Poor
PATIENTS WITH NO PREVIOUS UROLOGIC SURGERY
4 5 6
Weak detrusor contraction at 8 cc None None None None None
4
6
Normal
48
Poor Poor Poor Poor Normal
Incontinent
tromyographic recordings were made during all pressure measurements Simultaneous bladder and urethral pressures Following the initial profile determination and based on the data obtained in those studies and under fluoroscopic control the urethral perfusion aperture was positioned in a selected urethral
UROLOGY
JULY 975
VOLUME VI NUMBER
area during bladder filling Measurement of urethral responses to voiding efforts could then he made from a specific urethral area Results Seven patients were evaluated for poor results following transurethral resection Four of these patients were incontinent but three were unable to void satisfactorily Table I All showed poor
65
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u Soaoi~io•a•nnw FIGURE A and B Simultaneous bladder and urethral pressures in twenty seven year old man after intervertebral disk herniation and transurethral pros tatic resection Urethral profile shows activity only in area of external sphincter; with urethral perfusion aperture at this level attempt at voiding is recorded Increase in EMG activity and parallel elevation in bladder and urethral pressures also shown Open pros tatic urethra shown on radiograph 9 mm taken dur ing voiding attempt Urethral perfusion aperture positioned just at area of urethral narrowing BN = bladder neck; PU = bladder neck to 5 cm from bladder neck; S = 5 to 4 cm from bladder neck
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a r∎∎r ~u~wr~rr∎d∎wow∎rrww6es®w~ := ∎ ~® e fw∎ ~∎C∎∎~iE® A and B Urethral and bladder pressures EMG and urethral profile of patient incontinent after No urethral profile abdominal perineal resection for rectal carcinoma and transurethral prostatic resection X squeeze increase attempt to hold urine voluntarily are isobaric; during response shown; bladder and urethra shown in perineal muscular activity which is not reflected in urethral pressure Free urinary leakage shown on 9 mm film taken with patient in upright position BN = to 5 cm M U = 5 to 5 cm and SP = 5 to 5 cm from bladder neck FIGURE 4
detrusor function and the onset of the urethral profile response did not occur at the bladder neck but rather at apoint to cm distal to the bladder neck The bladder and proximal to cm of urethra appeared to act as a single isobaric chamber Fluoroscopy demonstrated an incom
66
petent bladder neck and prostatic urethra The results ofthe functional evaluation of detrusor and sphincter function in these patients are given in Table II Patients with persistent difficulty in voiding after transurethral resection preserved profile
UROLOGY
JULY 975
VOLUME VI NUMBER I
A and B Bladder and urethral pres sures and EMG in patient unable to void satisfactorly after lumbar disk herniation Urethral profile shows normal response in both prostatic and membranous urethra Perfusion aperture replaced in membranous urethra during attempts to hold urine voluntarily squeeze Appropriate increase shown in membranous urethral pressure indicating competence of voluntary sphincter Competent bladder neck shown in 9 mm film BN = to 5 cm from bladder neck ; PU prostatic urethra 5 to 5 cm from bladder neck ; MU = membranous urethra 5 to 4 cm from bladder neck; BU = bulbous urethra FIGURE 5
A
responses in area of urethra from to 5 cm from the bladder neck The mean effective urethral length in these patients was cm approximately half that seen in normals The preservation of profile responses was associated with a normal
UROLOGY
JULY
975
VOLUME V[ NUMBER
perineal electromyographic recording Attempts to hold urine voluntarily resulted in an elevated urethral pressure with a concomitant increase in electromyographic activity In these patients voiding was accomplished by straining; during
67
these efforts urethral resistance rose in associ ation with an increase in perineal floor elec tromyographic activity resulting in a poor inter mittent urinary stream with a large residual urine volume The urethral pressure rise in association with the Valsalva maneuver did not appear to be true external sphincter spasm but rather an ap propriate muscular contraction of the perineal floor as a part of the effort to increase intra abdominal pressure Fig These patients were treated with an external sphincterotomy In patient severe incontinence resulted which im proved after ten weeks and all now have a good result and are voiding without difficulty with no residual urine The 4 patients who were incontinent after transurethral resection showed no urethral profile response from the bladder neck to the bulbous urethra Three ofthese patients had poor perineal floor electromyographic activity proba bly as a result of a primary neurologic injury However I patient preserved normal perineal floor electromyographic activity but this was not reflected in membranous urethral resistance It appears to be due to an injury to the membranous urethra at the time oftransurethral resection with resulting scarring and rigidity Figure 4 is a pres sure tracing from this patient with a 9 mm radiographic exposure Two of the incontinent patients were treated with a Kaufman silica gel incontinence prosthesis and I patient underwent construction of a neoprostatic urethra from an anterior bladder flap One patient has been conti nent eight months with a prosthesis but the others have persistent incontinence Patients studied prior to urologic surgery all had urinary retention Table I The results of detrusor and urethral sphincter evaluation of these patients are given in Table II Patient preserved marginal detrusor function and dem onstrated both a competent bladder neck and normal membranous urethral function Fig 5 He underwent a transurethral resection with a good result This was the sole patient who dem onstrated normal prostatic and distal urethral 4 and 5 showed sphincter function Patients no detrusor function no urethral profile re sponse and no change_ in urethral pressure with attempts to hold urine voluntarily Perineal EMG activity was poor All of these patients had under gone abdominal perineal resection and were in continent in the standing position but tolerated large bladder volumes when in supine position Figure 6 is a bladder and urethral pressure tracing in one ofthese patients three weeks after abdomi
68
nal perineal resection A preoperative urody namic evaluation had been performed in this patient Figure 7 shows urethral profiles obtained be fore and after abdominal perineal resection and after treatment with ephedrine Two of these pa tients were treated with ephedrine with im mediate improvement in urinary control but two were not treated In the latter urinary control has slowly improved but both still suffer from stress urinary incontinence Patient 6 had urinary retention after removal of a herniated lumbar disk and showed preservation of proximal urethral profile responses and in creased membranous urethral pressure on strain ing to void He underwent an external sphinc terotomy with a good result ; he is continent voids by straining and has no residual urine Comment Urinary retention in patients following abdom inal perineal resection or lumbar intervertebral disk herniation is not always accompanied by in creased outlet resistance Urinary sphincter deficiencies may occur in conjunction with de trusor failure Detrusor dysfunction may mask incontinence since these patients when in supine position commonly tolerate large bladder vol umes without leakage Thus incontinence which existed prior to urologic surgery may be accepted as a result of surgery unless these patients are in the standing position when evaluated Three types of sphincter weakness appeared in the group of patients reported : isolated defi ciency ofprofile response in the bladder neck and first to cm of urethra; isolated deficiency of the skeletal muscular component of urethral re sistance manifested by poor perineal floor EMG activity and diminished profile responses in the area from to 5 cm from the bladder neck; and absence of any measurable urethral sphincter ac tivity which appeared to be a combination of the first two conditions Urethral smooth muscle is responsive to sym pathetic stimulation and urethral smooth muscle tone may be partially under sympathetic nervous control The findings in these patients appear to he explainable in the light ofthis concept of urethral function The patients with lumbar intervertebral disk herniation preserved proximal urethral pro file responses prior to transurethral resection This would be expected since the hypogastrie plexus would not be injured by a lumbar disk
UROLOGY
I
JULY 975
VOLUME VI NUMBER
FIGURE 6 Bladder and urethral pressures with perineal EMG in patient incontinent after abdominal perineal resection No effective urethral response shown; poor EMG activity Free urinary leakage shown on 9 mm film taken with patient in upright position BN = to 5 em from anatomic bladder neck seen fluoroscopically ; PU = 5 to cm and S = to 4 5 cm from bladder neck ; BU = bulbous urethra; PU = aperture at 5 cm
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®r®®∎®~∎∎a®~®®®~~~ •~~~∎∎~®~®®~~~ herniation However some of these patients showed absent profile responses in the area most closely associated with urethral skeletal muscle If they were subjected to transurethral resection incontinence resulted In patients with preserva UROLOGY
JULY 975
VOLUME VI
NUMBER I
tion of membranous urethral function and ab sence of detrusor activity a transurethral resec tion did not result in resumption of adequate voiding In these patients voiding by straining was impeded by an increase in urethral resistance
69
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which appeared to be due to increased muscular activity of the pelvic floor during the Valsalva maneuver External urethral sphincterotomy seems to be the treatment of choice in such pa tients but incontinence is likely to result if a prior transurethral resection has been performed Ad ditionally some patients with lumbar interver tebral disk herniation who preserve proximal urethral resistance but not skeletal muscular function became incontinent after transurethral resection since urethral smooth muscle function was the only remaining component of urethral resistance It seems preferable to treat these pa tients with intermittent self catheterization or administration of phenoxybenzamine to provide a reversible decrease in proximal urethral resis tance 6 Four patients studied following abdominal perineal resection but prior to transurethral re section showed complete failure of both smooth and skeletal muscular components of urethral re sistance Some return of urethral profile activity was seen after the administration of ephedrine and after a time urethral smooth muscular func tion appeared to improve spontaneously Such improvement has been reported by others Transurethral resection in these patients ap peared to impair permanently spontaneous re covery of urethral smooth muscular function Ad ditionally some patients preserved either skeletal or smooth muscular function after abdominal perineal resection If smooth muscular function was impaired a transurethral resection did not improve voiding ; if skeletal muscular function was impaired a transurethral resection resulted in in continence Moreover urologic evaluation prior to abdominal perineal resection was not reliable as total sphincter failure occurred in one such patient who might require prostatectomy follow ing surgery
7
An upright cystogram with urethral catheter removed which demonstrates a patulous open bladder neck is evidence that a transurethral re section is not likely to be beneficial In the ab sence of this finding that is with a competent bladder neck a simple pressure profile as de scribed by Edwards and Thomas 9 can be per formed at the bedside to evaluate membranous urethral function Urethral pressure should be active over a 4 cm length with a brisk pressure rise in the segment between cm and 4 cm from the bladder neck when the patient attempts to hold urine voluntarily If no membranous ure thral function is measurable a transurethral re section should be avoided since incontinence is likely to result 789 Howard Avenue New Haven Connecticut 65 4 DR M C GUIRE References
4 5 6 7 8 9
COMARU A E : Transurethral vesical neck resection ; an adjunct in the management of the neurogenic bladder J Urol 7 : 849 954 BRAASCH W F and THOMPSON G J : Treatment of the atone bladder Surg Gynec Obstet 6 : 79 9 5 LAPIDES J : Urologic complications of abdominal 974 perineal surgery Contemp Surg 5 : 8 BROWN M and WICKHAM J E A : The urethral 969 pressure profile Br J Urol 4 : EDWARDS L and MALVERN J : The urethral pressure profile ibid 46 ; 5 974 KRANE R J and OLSSON C A : Phenoxybenzamine : 65 in neurogenic bladder dysfunction J Urol 97 KLEEMAN F J ; The physiology of the internal urinary sphincter ibid 4 : 549 97 GLASS R L and SPRATn J S : Urinary complications ofabdominal perineal resection in men Am Surgeon 4 : 8 968 EDWARDS L F and THOMAS D : A simplified system for urodynamic observations Br J Urol 4 : 6 97
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