How do you treat intrinsic sphincter deficiency and sensory neurogenic bladder dysfunction in patients after spinal surgery?

Treatment of Intrinsic Sphincter Deficiency and Sensory Neurogenic Bladder Dysfunction After Spinal Surgery

For intrinsic sphincter deficiency after spinal surgery, offer slings as first-line surgical treatment in appropriately selected patients with acceptable bladder storage parameters, or consider artificial urinary sphincter in select cases, while for sensory neurogenic bladder dysfunction, initiate clean intermittent catheterization combined with anticholinergic medications to achieve low-pressure storage and complete emptying. 1

Initial Assessment and Risk Stratification

Before initiating any treatment, you must perform urodynamic studies to assess bladder storage parameters and ensure that outlet procedures will not create dangerously elevated storage pressures that threaten upper urinary tract function. 1 This is absolutely critical because worsening bladder compliance from an outlet procedure can lead to renal damage in patients with relevant neurogenic lower urinary tract dysfunction. 1

Key assessment parameters include:

• Voluntary anal contraction (VAC) presence—95.7% of patients without VAC have persistent impaired bladder function at follow-up 2
• Perineal sensation—absence of pinprick sensation in the perineal area predicts poor bladder recovery 1
• Urethral and rectal sphincter function—reappearance of voluntary external anal/urethral sphincter contraction significantly correlates with bladder recovery (P < 0.01) 1
• Post-void residual volumes to identify overflow incontinence 3

Treatment Algorithm for Intrinsic Sphincter Deficiency

First-Line Surgical Options

Slings should be offered to patients with stress urinary incontinence who can spontaneously void. 1 The AUA/SUFU guidelines provide a moderate recommendation (Grade C evidence) for this approach. 1 If there is concern for future need for clean intermittent catheterization, use autologous fascia or other biologic grafts rather than synthetic materials. 1

Second-Line Surgical Options

Artificial urinary sphincter (AUS) may be offered to select patients with acceptable bladder storage parameters. 1 However, you must counsel patients about:

• Risk of voiding dysfunction requiring clean intermittent catheterization post-implantation 1
• Need for adequate upper extremity function to manipulate the AUS device 1
• Failure rates of approximately 24% at 5 years and 50% at 10 years 3

Minimally Invasive Options

Urethral bulking agents may be considered but counsel patients that efficacy is modest and cure is rare. 1 This is a conditional recommendation with Grade C evidence, and there is a paucity of literature evaluating this treatment specifically in neurogenic bladder populations. 1

Last Resort Option

Bladder neck closure with concomitant bladder drainage may be offered to patients with refractory stress urinary incontinence after thorough discussion of risks. 1 This irreversible procedure is reserved for patients who have failed all other forms of urethral reconstruction or have severe urethral pathologies such as strictures or urethrocutaneous fistula. 1 Continence rates range from 75-100%, but fistulization with recurrent incontinence occurs in up to 25% of cases. 1

Treatment Algorithm for Sensory Neurogenic Bladder Dysfunction

First-Line Conservative Management

Initiate clean intermittent catheterization (CIC) as the primary bladder emptying method rather than indwelling catheters. 1 This is a strong recommendation (Grade C evidence) because CIC has significantly lower rates of urinary tract infections, urethral trauma, and bladder stones compared to indwelling catheters. 1 The best quality of life is associated with ability to self-catheterize. 1

Combine CIC with anticholinergic medications or beta-3 adrenergic receptor agonists to improve bladder storage parameters. 1 The primary goal is to achieve adequate bladder drainage, low-pressure urine storage, and low-pressure voiding to prevent urinary tract infections, bladder wall damage, vesicoureteral reflux, and stone disease. 4

Second-Line Medical Management

For patients refractory to oral medications, offer onabotulinumtoxinA (200-300 units) intradetrusor injections. 1 This reduces incontinence episodes, increases maximum cystometric capacity, and decreases maximum detrusor pressure. 1 However, you must discuss the specific risk of urinary retention (20.49% vs 3.67% for placebo) and potential need for intermittent catheterization prior to treatment. 1

There is no efficacy difference between 200 U and 300 U doses, but there is an increasing dose-dependent relationship regarding retention risk and need for CIC. 1

Surgical Options for Refractory Cases

For male patients with detrusor sphincter dyssynergia who are unwilling or unable to perform CIC, offer sphincterotomy. 1 This irreversible procedure allows reflex voiding with condom catheter drainage and can increase bladder emptying effectiveness, decrease UTIs, and preserve upper urinary tract function. 1 However, counsel patients about high risk of failure or need for additional treatment. 1

For patients refractory to all therapies with elevated storage pressures, strongly consider bladder augmentation or urinary diversion. 1 These are last-resort options when stepwise therapy fails to achieve safe storage pressures. 1

Critical Monitoring Requirements

Perform urodynamic studies at appropriate intervals to assess treatment effectiveness, particularly after sphincterotomy or any outlet procedure. 1 Multichannel urodynamics documents reduction in intravesical storage pressures and confirms efficacy. 1

Assess patients annually with focused history, physical exam, basic metabolic panel, and urinary tract imaging if they have undergone lower urinary tract reconstruction incorporating bowel segments. 1 These patients are at risk for metabolic disturbances, recurrent UTIs, and malignancy. 1

Common Pitfalls to Avoid

Do not perform outlet procedures (slings, AUS, bladder neck closure) without first confirming acceptable bladder storage parameters on urodynamics. 1 Worsening bladder compliance from increased outlet resistance can create dangerously elevated storage pressures that damage the upper urinary tracts. 1

Do not recommend indwelling catheters when CIC is feasible. 1 Indwelling catheters have significantly higher complication rates including UTIs, bladder stones, and worse quality of life. 1 For patients requiring chronic indwelling catheterization, suprapubic catheterization is strongly recommended over urethral catheters. 1

Do not delay urodynamic evaluation in patients with spinal cord injury. 5 In a long-term study, treatment strategy had to be modified in almost all patients (97%), with 18.8% requiring surgery to protect upper urinary tracts. 5 Regular urodynamic follow-up is warranted for maintenance of continence and renal protection. 5

Do not assume bladder function is static after spinal surgery. 2 Bladder dysfunction is dynamic following traumatic spinal cord injury, and 94.7% of patients diagnosed with bladder dysfunction during acute care reported impaired function at 3-month follow-up. 2