Neurogenic urinary incontinence: current treatment concepts

Neurogenic urinary tract dysfunction is characterized by inadequate voiding and urinary incontinence. The aim of therapy nowadays is adequate bladder emptying and control of urinary incontinence. Neurogenic urinary incontinence can be caused by (a) detrusor hyperreflexia, (b) sphincter hypo- or areflexia, (c) a combination of both, or also (d) detrusor hyporeflexia with consequent overlow incontinence. Based on a simple urodynamic classification the current treatment strategies are presented. (a) Detrusor hyperreflexia can be transformed into hypo- or are-flexia pharmacologically with potent drugs now available. Bladder emptying then has to be assisted or can be achieved by intermittent catheterization. If conservative therapy fails, sacral posterior root rhizotomy together with implantation of a sacral anterior root stimulator (Brindley) is an alternative, especially for women. If the anatomical situation does not allow sacral deafferentation (e.g. in patients with myelomeningocele or sacral dysplasia) bladder augmentation is the method of choice: a detubularized segment of ileum will serve as an energy destroyer for the pressure resulting from uncontrollable detrusor contractions. In contrast to detrusor hyperreflexia (b) hypo- or areflexia of the sphincter cannot be influenced pharmacologically. Method of choice for restoration of urinary continence in these patients is the implantation of a hydraulic sphincter system (Scott); in this way urinary continence is achieved without creating outflow obstruction. The alternative is conventional colposuspension with maximal elevation of the bladder neck in order to create bladder neck outflow obstruction allowing the achievement of continence. In this situation intermittent catheterization is essential for bladder emptying (and can sometimes be difficult). If (c) detrusor hyperreflexia is combined with sphincter hypo- or areflexia, urinary incontinence is due to detrusor and sphincter dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)