1978 Volume 69 Issue 6 Pages 730-742
There is a group of cases who show the clinical features of obstructive uropathy but neither anatomical obstruction nor neurological disorder. After introduction of urodynamic examinations to the lower urinary tract, this subclinical or occult neurogenic bladder dysfunction is frequently detected not only in the patients with severe obstructive lesions, but also in the patients with recurrent urinary tract infection and/or slight urination disorders.
1. Consideration for possible neurological lesions:
The age distribution chart of subclinical neurogenic bladder cases is very similar to that of neurogenically evident bladder dysfunction cases. The cases of neurogenic bladder clearly show the peculiar variety and incidence in each generation. Therefore, when the diagnosis of subclinical neurogenic bladder is made, it should be asked first of all whether the thorough neurological examinations have been made to find the causal diseases.
2. Subdivision of vesico-urethral dysfunctions and the possible site of neurological lesions:
Even in the same group of patients with the same neurological disease, such as meningomyelocele or cerebrovascular lesion, the urodynamic features are variable, and the nature of their vesico-urethral dysfunctions could be subdivided based on detrusor and sphincter reflex activities, detrusor-sphincter coordination, and voiding cystourethrographic pattern. However, these proceedings of classification do not necessarily simplify the complicated problem, “the decision of the site of neurological lesions”.
3. Uninhibited bladder:
The age distribution chart of all the cases with uninhibited bladder contraction shows the characteristic curve of parabola, in which the overwhelming majority of the cases are distributed in young children. Contrary to the high incidence of mechanical obstruction or organic disease in old patients, most of these children can not be proven to have any neurological defect, though organic urethral stenosis, including Lyon's Ring, is detectd in less than half of them.
Even after excluding these mechanical obstruction or evident neurogenic bladder dysfunction, functional bladder neck obstruction or external sphincter spasm can be demonstrated in some of these uninhibited bladder cases, and all of them have positive urinary tract infection.
4. The causal background of enuresis:
Uninhibited bladder contraction can be detected in most of the enuretic children, but its incidence decreases rapidly after 10 years of age, and is replaced by other types of bladder dysfunction such as reflex bladder in elder children and adults.
Anticholinergic drugs and/or Imipramine are used routinely in its treatment, but these drugs are not effective in the cases whose internal sphincter mechanism is weak. In these cases, combination of Imipramine or anticholinergic drugs with GOMT-inhibitor that elevates endogenous norepinephrine activities, thus increasing alpha-adrenergic response, are successful.
5. Hypotonic or large bladder:
If one excludes patients with obvious outflow obstruction, the detection rate of hypotonic or large bladder is high in patients with recurrent or persistent cystitis in females and chronic prostatitis in males.
Although neurological lesions can not be detected by the usual neurological examination, spinal deformities on X-ray such as spina bifida occulta and spondylosis deformans are frequently visible both in children and adults. In middle aged people, the characteristic clinical histories, such as delivery in female, lumbar or ischiatric neuralgia, and perineal discomfort in both sexes are heard very often. In addition, disturbed detrusor and sphincter reflex activities, and abnormal decrease of UPP to alpha-blocker are constantly detected in these patients. These results are suggestive of the incomplete lesions of peripheral nerves concerned with micturition, probably at the level of the roots of the lumbar spinal nerves, cauda e
