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TREATMENT OF NEUROGENIC LOWER URINARY TRACT DYSFUNCTION IN REHABILITATION OF DISABLED PERSONS WITH TRAUMATIC SPINAL CORD INJURY Palatkin P.P., Filatov E.V., Boshchenko V.S., Baranov A.I.

Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons, Novokuznetsk, Russia

Siberian State Medical University, Tomsk, Russia

Novokuznetsk State Extension Course Institute for Medical Practitioners – Affiliated Branch of  Russian Medical Academy of Continuing Vocational Education, Novokuznetsk, Russia

 

According the data from the World Healthcare Organization, spine and spinal cord injury is the main cause of death and disability in young people. Among all injuries in adult population, it consists of 0.7-20.3 % [1], with incidence of 0.6-0.8 per 1,000 of population [2]. The costs for treatment of spine and spinal cord injury is much higher than for other injuries [3]. Most patients with such pathology has high percentage of disability and social disadaptation [4].

Almost all patients with spinal cord traumatic disease (SCTD) have neurogenic dysfunction of lower urinary tracts (NDLUT). NDLUT can cause complications due to inadequate draining of the urinary bladder at the background of urine dynamics disorder [5]. Any manifestations of disorder of pelvic organs strongly decrease the life quality, and create mental and social difficulties [1].  

Objective − to compare the results of different methods of treatment of neurogenic lower urinary tract dysfunction used in rehabilitation of the disabled persons in the late period of traumatic spinal cord injury.

 

MATERIALS AND METHODS

The study included all patients of the neurosurgery unit of Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons. There were 201 case histories of patients with late period of SCTD who were admitted in the period from November 1, 2011, to December 31, 2017. The protocols of neurologic and urologic examination were examined. There were 45 (22.4 %) men and 156 (77.6 %) women. Most patients had the disability of the group 1 − 185 (92.1 %), group 2-3 − 16 (7.9 %). The injuries happened 1-5 years ago in 57.7 % (6.9 ± 0.5 years on average).

A spine and spinal cord injury in the cervical part was in 70 (34.8 %) patients, in the upper thoracic region − in 35 (17.4 %), in the lower thoracic tract − in 54 (26.9 %), in the lumbar region − in 42 (20.9 %). Neurological disorders of type A were in 59 (29.4 %) patients, type B − in 59 (29.4 %), type C − in 56 (27.8 %), type D − in 27 (13.4 %).

A spine injury level was determined on the basis of X-ray imaging. Estimation of a level of neurological disorders was conducted during neurological examination in correspondence to the recommendations from American Spinal Injury Association (ASIA).

The complex urodynamic examination (CUDE) was carried out for clarification of patterns of urinary bladder neurogenic dysfunction. If NDLUT was diagnosed, the classification by Н. Madersbacher was used [6]. 4 groups were separated on the basis of the classification with consideration of disordered function of the detrusor: the group 1 − normoactive detrusor −14 (6.9 %), the group 2 − hypoactive detrusor − 65 (32.3 %), the group 3 − hyperactive detrusor − 82 (40.8 %), the group 4 − epicystostoma and constant urethral catheter − 40 (19.9 %) patients. The groups were formed according to increasing severity of urination disorder.

The efficiency of ways for correction of NDLUT in the neurosurgery unit was estimated: tibial stimulation, urinary bladder electric stimulation, endosacral blockades with proserine, pudental blockades with local anesthetics, needle reflex therapy, urinary bladder correction. All patients received only single type of correction. Patients with combination of several types of correction were not included into the study.

The efficiency of correction techniques for NDLUT was estimated with ICIQ-SF (application 1) [7]. The correction effect was estimated as positive in case of improvements in results of questioning (as compared to the basic level) by more than 3 points (on the 7th day after initiation of treatment).

The statistical reliability of the data was estimated with mathematical statistical methods. The absolute number and relative value (%) were indicated for qualitative signs. Pearson's test was used for estimation of differences in absolute and relative rates, proportions and ratios in two independent samples. A relationship between the signs was analyzed with Spearman's paired lineal correlation (r).

Statistical calculations were conducted with Statistica 10.0.1011.0.

The study corresponded to the standards of Helsinki Declare − Ethical Principles for Medical Research with Human Subjects, and the Rules for Clinical Practice in the Russian Federation, with approval from the ethical committee of Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons.

 

RESULTS

The figures 1 and 2 show the data on incidence of various types of NDLUT in dependence on a spine and spinal cord injury level, and a degree of neurological deficiency.

Table 1

Comparison of the methods of treatment of neurogenic lower urinary tract dysfunction depending on the type of micturition disorder, number of cases (n = 97)

Type of neurogenic dysfunction of lower urinary tracts / Treatment type		Normoactive detrusor (group 1), n = 5	Hypoactive detrusor (group 2), n = 36	Hyperactive detrusor (group 3), n = 46	Epicystostomy and indwelling urethral catheter (group 4), n = 10
Monro system (n = 3)	without effect (abs., %)	0 (0)	1 (100,0)	1 (100,0)	1 (100,0)
	improvement (abs., %)	0 (0)	0 (0)	0 (0)	0 (0)
Urinary bladder electric stimulation (n = 26)	without effect (abs., %)	1 (33.3)	8 (53.3)	1 (12.5)	0 (0)
	improvement (abs., %)	2 (66.7)	7 (46.7)	7 (87.5)	0 (0)
Tibial stimulation (n = 24)	without effect (abs., %)	0 (0)	3 (75.0)	3 (18.8)	3 (75.0)
	improvement (abs., %)	0 (0)	1 (25.0)	13 (81.2)	1 (25.0)
Pudendal blocks with novocaine (n = 10)	without effect (abs., %)	0 (0)	5 (100.0)	2 (50.0)	1 (100.0)
	improvement (abs., %)	0 (0)	0 (0)	2 (50.0)	0 (0)
Endosacral blocks with proserin (n = 20)	without effect (abs., %)	0 (0)	0 (0)	7 (70.0)	0 (0)
	improvement (abs., %)	2 (100.0)	8 (100.0)	3 (30.0)	0 (0)
Acupuncture (n = 3)	without effect (abs., %)	0 (0)	0 (0)	0 (0)	0 (0)
	improvement (abs., %)	0 (0)	0 (0)	0 (0)	3 (100.0)
Correction of urinary bladder volume (n = 11)	without effect (abs., %)	0 (0)	3 (100.0)	3 (42.9)	0 (0)
	improvement (abs., %)	0 (0)	0 (0)	4 (57.1)	1 (100.0)

The correlation analysis of dependence of severity of NDLUT on a level of a degree of a spinal cord injury showed that a relationship between a spine injury level and a degree of clinical manifestations of NDLUT was characterized with r coefficient = 0.48, p = 0.001; between a degree of neurological deficiency and a degree of clinical manifestations of NDLUT − r = 0.35, p = 0.001: the higher level of a spine and spinal cord injury, the more intense degree of clinical manifestations of NDLUT.

Correction of NDLUT was not conducted for 104 patients: 15 (14.4 %) patients did not require for correction, 42 (40.4 %) patients did not receive correction owing to acute urologic pathology (urinary tract obturation − 9.6 %, acute inflammation of urinary system organs − 30.8 %), 47 (45.2 %) patients refused from correction.

In other 97 cases, correction of NDLUT was not conducted.

In the group 1, most patients with NDLUT achieved improvement as result of correction with electric stimulation and endosacral blockades.

In the group 2 of patients with NDLUT, correction was efficient in  almost half of cases of electric stimulation and in all cases of endosacral blockade of urinary bladder with proserine.

In the group 3, the improvement was noted in most patients as result of electric stimulation and tibial stimulation in a half and more cases after pudendal blockades and correction of urinary bladder volume.

In the group 4, the improvement in all cases was associated with needle reflex therapy and urinary bladder volume correction. The comparison of results of use of various techniques for correction of NDLUT showed that the positive effect was more often achieved with tibial stimulation, urinary bladder electric stimulation and endosacral blockades with proserine. The use of pudental blockades and Monro system was inefficient. The results are presented in the table 2.

Table 2

Results of neurogenic lower urinary tract dysfunction treatment with different methods, n = 97

Type of correction of   neurogenic dysfunction of lower urinary tracts	Total number of corrections	Correction efficiency	Results of correction (abs., %)
Monro system	3	without effect	3 (100.0 )
		improvement	0 (0.0)
Urinary bladder electric stimulation	26	without effect	10 (38.5)
		improvement	16 (61.5)
Tibial stimulation	24	without effect	9 (37.5)
		improvement	15 (62.5)
Pudendal blocks with novocaine	10	without effect	8 (80.0)
		improvement	2 (20.0)
Endosacral blocks with proserin	20	without effect	7 (35.0)
		improvement	13 (65.0)
Acupuncture	11	without effect	6 (54.5)
		improvement	5 (45.5)
Correction of urinary bladder volume	3	without effect	0 (0.0)
		improvement	3 (100.0)

 

DISCUSSION

A clear positively associated relationship of a degree and a level of a spinal cord injury with intensity of clinical manifestations of NDLUP was found. It means the necessity for adequate attention for patients with severe neurological disorders owing to the risk of urologic complications of NDLUT. The similar results were received in the analyzed studies [8].

The comparative analysis showed tibial stimulation for patients with hyperactive detrusor as the most efficient method of treatment. The positive results of this technique were achieved in 25-40 % in the analyzed literature [9, 10].

Also good results were achieved for urinary bladder electric stimulation. It was noted in the analyzed literature [11, 12].

The use of endosacral blockades with proserine was efficient. However, this technique is not recommended for wide-spread use for NDLUT owing to the risk of reflux into upper urinary tracts in some patients.

Monro system showed the lowest efficiency. It was probably associated with its common use for patients in early period after injury [5, 13, 14], and the fact that all patients were injured more than a year ago. Due to the rare use of this technique, it is impossible to compare its efficiency.

One would think that any patient wants to get rid of existing problems, but correction of urologic disorders was not conducted in 45 % due to refusal of patients (fear of changes or associated discomfort, or fear of changes in usual style of life). The literature includes some data on high incidence of depression and anxiety, as well as dysmorphic disorder in patients with spinal disorders [15, 16]. Possibly, the reason of refusal from correction of NDLUT consists not only in aversion to changes something, but also in mental disorders and changes in behavioral reactions.

So, in the analyzed literature, as well as in our study, the only  objective reasons of refusal from urological correction in patients with NDLUT was presence of acute conditions (urinary tract obturation and acute inflammation of urinary system). In our study, the proportion of such patients was 21 % from total amount of patients. According to the literature data, the percentage of acute urological disorders can achieve 77 % [17]. However, occurrence of most acute disorders can be minimized or prevented completely in case of timely examination by neurourologist (urologist).

 

CONCLUSION

In the late period of SCTD, the best results of NDLUT correction were achieved with use of tibial stimulation, urinary bladder electric stimulation and endosacral blockades. Other techniques of correction were low efficient.

Realization of correction of NDLUT limits the presence of acute urologic pathology and negative opinions of patients in relation to possible changes in usual life style.

Treatment of patients with NDLUT in the late period of SCTD should be initiated with neurourological examination, CUDE, identification and prevention of secondary complications of NDLUT, psychoemotional correction, social and home adaptation, learning of a patient and his/her relatives to use technical methods of rehabilitation.

The use of any technique for correction of NDLUT in patients in the late period of SCTD, including routine methods such as physical therapy, blockades, needle reflex therapy, is the obligatory part of the whole complex of rehabilitation treatment with use of technical methods of rehabilitation.

 

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publications of this article.