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Case Based Urology Learning Program: Resident's Corner: UROLOGY

This case discusses a 22-year old woman with multiple sclerosis presenting with urinary hesitancy and weak stream who is diagnosed with detrusor sphincter dyssynergia based on her elevated post-void residual, urodynamics showing elevated detrusor pressure and EMG activity during voiding, and cystoscopy findings. She is treated with botulinum toxin A injections which improve her symptoms, and further treatments are performed as needed based on symptom recurrence.

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Abdullah Bangwar
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46 views

Case Based Urology Learning Program: Resident's Corner: UROLOGY

This case discusses a 22-year old woman with multiple sclerosis presenting with urinary hesitancy and weak stream who is diagnosed with detrusor sphincter dyssynergia based on her elevated post-void residual, urodynamics showing elevated detrusor pressure and EMG activity during voiding, and cystoscopy findings. She is treated with botulinum toxin A injections which improve her symptoms, and further treatments are performed as needed based on symptom recurrence.

Uploaded by

Abdullah Bangwar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Case Based Urology Learning Program

Resident’s Corner: UROLOGY

Case Number 21

CBULP 2011‐068
Case Based Urology Learning Program 
Editor: Steven C. Campbell, MD PhD
Cleveland Clinic

Associate Editors: Jonathan H. Ross, MD
Rainbow Babies & Children’s Hospital, UH
David A. Goldfarb, MD
Cleveland Clinic
Howard B. Goldman, MD
Cleveland Clinic

Manager: Nikki Williams
Cleveland Clinic

Case Contributors: Alana Murphy, MD, and Howard B. Goldman, MD
Cleveland Clinic
A 22 year old woman with a two year history of multiple sclerosis 
presents with a complaint of urinary hesitancy and weak stream over 
the past 6 months. 

What are common causes of urinary 
hesitancy and weak stream in a 
woman?
What are common causes of urinary hesitancy and 
weak stream in a woman?
Outlet:
Dysfunctional voiding
Primary bladder neck obstruction
Detrusor sphincter dyssynergia
Obstructive periurethral mass (e.g., Urethral diverticulum)
Pelvic organ prolapse
Bladder:
Detrusor underactivity
Acontractile detrusor
What elements of the office exam are 
most critical when evaluating urinary 
hesitancy and weak stream in a 
woman?
What elements of the office exam are most critical 
when evaluating urinary hesitancy and weak stream 
in a woman?
Abdominal exam:
Signs of poor emptying—distended lower abdomen, palpable 
bladder
Pelvic exam:
Fluctuance or mass on anterior vaginal wall
Inspection of meatus
Pelvic organ prolapse
Exclude urethral cancer or other obstructive mass
Post‐void residual
Her abdomen is soft and non‐distended.  Her pelvic exam is normal 
with no periurethral mass or prolapse.  Her PVR is 171 mL.

What is your leading diagnosis for this 
young woman with multiple sclerosis?
What is your leading diagnosis for this young woman 
with multiple sclerosis?

Detrusor sphincter dyssynergia (DSD)
What is detrusor sphincter 
dyssynergia?
What is detrusor sphincter dyssynergia?

Detrusor sphincter dyssynergia (DSD): incoordination between detrusor 


and external sphincter during voiding due to involuntary contraction or 
lack of relaxation of the sphincter in the setting of a neurologic 
abnormality.
What neurologic diagnoses are 
associated with DSD?
What neurologic diagnoses are associated with DSD?

Multiple sclerosis
Spinal cord injury
Transverse myelitis
What type of testing will allow you to 
make a definitive diagnosis?
What type of testing will allow you to make a 
definitive diagnosis?

Urodynamics (pressure flow study) with EMG and fluoroscopy (imaging 
is valuable in this setting to allow visualization of the outlet).

Cystoscopy
Fluro Urodynamics
Fluro Urodynamics Findings

Fluid infused at 30 mL/min.


Filling phase: first sensation at 16 mL, strong desire at 111 mL,
capacity 112 mL, no detrusor overactivity.
Voiding phase: voluntary void, voided 104 mL, high Pdet at Qmax of
95 cm H2O, Qmax 7 mL/sec, +++EMG activity during void
Fluoroscopy during void: clear proximal urethral dilation to level of
external sphincter.
Cystoscopy reveals a normal urethra and a mildly trabeculated
bladder.

Based on the clinical scenario, the 
urodynamics testing and the 
cystoscopy, what is your diagnosis?  
What are the key elements that 
support your diagnosis?
Based on the clinical scenario, the urodynamics testing 
and the cystoscopy, what is your diagnosis? What are the 
key elements that support your diagnosis?
Dx: Detrusor sphincter dyssynergia

Multiple sclerosis as a predisposing factor


Urinary hesitancy and weak stream in the history
Elevated PVR
Cystoscopy: mild trabeculation
UDS: elevated detrusor pressure (>20 cm H2O), low flow (<12 cm H2O)
and increased EMG activity during voiding phase
Fluoro: open bladder neck, dilation of proximal urethra to level of
external sphincter during voiding
What other studies should be 
considered for this patient with DSD?
What other studies should be considered for this patient 
with DSD?

Upper‐tract imaging to rule out upper‐tract changes may be considered.  
Given the low resting detrusor pressures, it is debatable whether the 
kidneys are at much risk.  Although the literature is mixed on this topic, 
many would obtain at least a baseline renal ultrasound.

Serum chemistry to confirm normal renal function.
What are the treatment options for 
this patient with DSD?
What are the treatment options for this 
patient with DSD?
Pharmacotherapy
Skeletal muscle relaxants: e.g., benzodiazapenes, baclofen (these 
medications are frequently ineffective)
Alpha blockers: often tried, may be effective in some cases
Clean intermittent catheterization
Indwelling catheter (not ideal for obvious reasons)
Injection of botulinum toxin A into the external urethral sphincter (THIS IS 
CURRENTLY AN OFF LABEL USE OF BOTOX)
Neuromodulation
Sacral nerve stimulation: successfully utilized, but it can be problematic 
implanting an   SNS device into a patient who may need future MRIs
Percutaneous tibial nerve stimulation: recent reports indicate good 
outcomes with this
Sphincterotomy: would potentially leave this patient totally incontinent (not 
a good idea)
Urinary diversion: last resort
She underwent treatment with transurethral injection of 100 units of
botulinum toxin A into her external urinary sphincter. A total of 100
units was diluted in 10 mL saline (10 µ/mL). Using a transurethral
technique, 2.5 mL (25 units) was injected in each quadrant of her
external sphincter in the office.

After the procedure, she experienced less urinary hesitancy and


improved force of stream. Her PVR was 57 mL during a follow‐up visit.
Botulinum toxin A injected into skeletal muscle is generally efficacious
for 5‐6 months.

Further treatments are performed based on recurrence of symptoms.


Selected Reading

Stoffel JT.  Contemporary management of the 
neurogenic bladder for multiple sclerosis patients.  
Urol Clin N Am 2010;37:547‐57.
Phelan MW, Franks M, Somogyi GT, Yokoyama T, et al.  
Botulinum toxin urethral sphincter injection to 
restore bladder emptying in men and women with 
voiding dysfunction.  J Urology 2001;165:1107‐10.
Gobbi C, Digesu GA, Khullar V, El Neil S, et al.  
Percutaneous posterior tibial nerve stimulation as an 
effective treatment of refractory lower urinary tract 
symptoms in patients with multiple sclerosis: 
preliminary data from a multicentre, prospective, 
open label trial.  Multiple Sclerosis J 2011;0(00):1‐6.
Topic:

Female Urology/Neurourology

Subtopics:

Multiple sclerosis and detrussor sphincter 
dyssynergia

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