Biomedical subjects
Publications and source records attributed to J B Nanninga.
During the last 2 decades various routes of investigation have enhanced our knowledge of the striated urethral sphincter. Anatomic and neurophysiological studies as well as clinical evaluation in the form of urodynamic studies have demonstrated the components of the sphincter and its function. This information has provided the urologist with greater understanding of problems related to striated sphincter function.
The role of electrocoagulation for the treatment of vesicovaginal fistulas has not been clearly defined. To determine the use of this therapeutic modality, 15 cases of fistulas treated with electrocoagulation were retrospectively reviewed. Fulguration represented the primary treatment in 12 patients and the secondary treatment in 3 after an initial attempt at open surgical closure failed. In all instances fistula size was estimated to be 3.5 mm. or less. A Bugbee electrode, which was inserted into the fistula either cystoscopically or vaginally, was used to destroy the epithelial lining of the fistula tract. Following the procedure the bladder was decompressed with a large indwelling Foley catheter for at least 2 weeks. Fulguration was successful as the sole treatment modality in 9 of 12 patients (75%) and as an alternative intervention after failure of an open surgical repair in 2 of 3 (66%). Therefore, 11 of the 15 women (73%) had complete resolution of the fistulas with this technique. We conclude that fulguration is usually effective in managing patients with vesicovaginal fistulas a few millimeters in size or less. This technique should be used as an initial treatment for appropriately selected patients and in women with small residual fistulas after open surgical failure.
A programmable baclofen pump was implanted in 7 patients for relief of severe spasticity. The patients experienced improvement in bladder and sphincter function. This system would seem to be of value in improving lower urinary tract function in patients with diseases that produce marked spasticity.
Neural stimulation was used to reduce bladder hyperreflexia and incontinence in a woman with myelodysplasia. The stimulation was delivered via an electrode placed in a sacral foramen and attached to a stimulator placed subcutaneously. The patient activated the device to inhibit the bladder and deactivated it to allow voiding. The device proved to be helpful in reducing bladder hyperreflexia and its use during pregnancy did not seem to have any adverse effect.
Relaxation of both detrusor and external sphincter muscles by mechanical stretch instead of cutaneous stimulation of the anal sphincter has been recognized and applied clinically for bladder emptying and for aiding catheterization in patients with spastic urethral sphincter. In a three-year study anal stretch was included as part of urodynamic examination in patients who could potentially use this method for bladder management. Anal stretch was found to inhibit the bulbocavernosus reflex and to be a useful alternative technique for bladder emptying in patients having complete paraplegia with normal hand function and with detrusor-sphincter dyssynergia. It is recommended that anal stretch combined with Credé or Valsalva maneuvers be a part of the urodynamic study of such patients to determine whether or not these techniques can be utilized for bladder management.
Intermittent catheterization was used as a means of long-term bladder management in 85 patients with spinal cord injury. Of these patients followup data revealed that 28 (33 per cent) had reflux and/or hydronephrosis. Treatment in 15 patients consisted of increasing the frequency of catheterization to every 4 hours and avoiding high fluid intake during a relative short interval. Sphincterotomy was done in 3 patients, while 10 were placed on an indwelling catheter because of an inability to adapt to or refusal of other forms of treatment. The upper urinary tract changes noted seemed to be related to increased intravesical pressure, either from too long an interval between catheterizations or from marked detrusor hyperreflexia with sphincter obstruction. Close followup seems necessary in these patients.
Urosonography, ultrasound of the urinary tract, is a noninvasive imaging method used to evaluate renal masses, renal parenchymal disease, hydronephrosis, bladder volume and calculi. The applicability of ultrasound was studied in 54 spinal cord injury patients by correlating uroradiological examinations with ultrasound. Emphasis was placed on ultrasonic imaging of ureterectasis and vesicoureteral reflux. Ultrasound confirmed all positive radiographic findings of renal and bladder abnormalities (renal calculi, chronic pyelonephritis, trabeculated bladder and bladder calculi), and yielded additional information in 27 per cent of the kidney and 13 per cent of the bladder studies. Ultrasound was used to confirm vesicoureteral reflux in 56 per cent of the patients and ureterectasis in 33 per cent. It is recommended that spinal cord injury patients undergo a baseline excretory urogram followed by periodical ultrasound examinations to detect hydronephrosis, renal parenchymal disease, and renal and bladder calculi, and to measure bladder volume and residual urine. Whenever real-time equipment and experienced ultrasonologists are available ultrasound can be used as an alternate to voiding cystourethrography to detect vesicoureteral reflux.
There are few reports on extensive suprapubic vesicocutaneous fistulas. We report the problems encountered in the closure of these fistulas following lower abdominal trauma. Two patients are described in whom the trauma produced extensive loss of skin, fascia and muscle, leaving the bladder exposed and open. Despite several attempts at bladder closure the bladder repair always failed and the fistula remained open. It was necessary to cover the subsequent bladder closure with overlying muscle, fascia and skin to obtain a successful closure. The techniques of closure are explained.
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Four patients with traumatic spinal cord injuries and paraplegia received electric stimulation of the conus medullaris. An additional 5 patients with traumatic spinal cord injuries and paraplegia received terbutaline for asthma. All 9 patients were studied with bladder and external urethral sphincter electromyography (EMG). Bladder pressures were recorded in the electric stimulation group and cystometry in the terbutaline group. The electric impulses were recorded without attenuation, and bladder and external urethral sphincter contractility increased. Terbutaline reduced the bladder's electric activity and pressure at capacity without affecting external urethral sphincter function. More evaluations of terbutaline's effect on the bladder are necessary to determine its applicability to incontinence problems.
A new resterilizable, low cost, and convenient catheter for long-term sterile intermittent catheterization of the neurogenic bladder is described. Average self-catheterization time is 2 minutes. It can be performed successfully in a wheelchair. Estimated average cost per catheterization is 10 to 20 cents. The reduced cost and greater convenience of the Wu Reusable Catheter make sterile long-term intermittent catheterization feasible for spinal cord injured patients. This should lead to reduction of urologic morbidity encountered with indwelling and external catheterization.
We studied 44 patients with spinal cord injury during the first 72 hours after injury to determine the functional status of the bladder and external urethral sphincter. The studies included determination of the bulbocavernosus reflex, cystometry and sphincter electromyogram. In patients with lesions above the sacral cord the bulbocavernosus reflex was present. In nearly all of these patients the external sphincter activity increased with bladder filling. In all but 1 patient with injury to the sacral cord the bulbocavernosus reflex could not be elicited and the sphincter electromyogram did not increase with bladder filling.
Six spinal cord injured patients were evaluated with cystometry, bladder electromyography, and external urethal spincter pressure profiles before and after propranolol hydrochloride administration. Bladder contractility was significantly augmented, and therefore was associated with decreased beta-sympathetic bladder stimulation. The results of these clinical neurophysiological investigations suggest inhibitory influences upon the smooth muscle of the human urinary bladder via beta-sympathetic receptors.
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In evlauating patients with neurologic lesions of the spinal cord and voiding abnormalities, it would appear from this study that distention is a more physiologic stimulus to bladder contraction than relatively smaller amounts of cold fluid. While the ice water test has speed and simplicity to recommend it, it should not be used as a sole means in determining whether or not a detrusor reflex is present. It may not uncover those patients with detrusor hyperreflexia or may fail to reveal a detrusor reflex. If iced contrast medium is to be used for voiding cystography, the volumes should approximate those used for regular cystometry.
Seven spinal cord injured patients were evaluated with cystometry bladder, electromyography, and pressure profiles of the external urethral sphincter before and after phenoxybenzamine administration. Seven more patients were evaluated before and after mecamylamine administration. Both drugs reduced the contractility of the bladder. The reduction of bladder contractility may reflect decreased sympathetic stimulation to the bladder. Bladder electric potentials reflect the intrinsic tone of the detrusor muscle.
A series of patients is presented in whom the recording of bladder electrical activity was performed. There was a significant difference in frequency of the spike activity between patients with upper and lower motor neuron injury. This technique would seem to offer greater clinical application in areas of bladder dysfunction and evaluation of drugs on the bladder.
Fourteen patients with spinal cord injuries and lower motor neuron type neurogenic bladders and 12 patients with upper motor neuron type neurogenic bladders and spinal cord injuries, were evaluated before and after bethanechol or atropine, respectively. They were compared with 5 patients with benign prostatic hypertrophy or bladder tumors but without neurologic disease. Both drugs were found to modify partially smooth-muscle response. The implications of these results are consistent with the production of electrical activity by the smooth-muscle cells of the bladder wall.