Editing Neurogenic LUT Dysfunction (section)

== Classification of Neuromuscular Dysfunction of the Lower Urinary Tract ==

* '''Classified based on location of disease: suprapontine, spinal, sacral/infrasacral'''

{| class="wikitable"
|'''Location of lesion'''
|'''History'''
|'''PVR'''
|'''Urodynamics'''
|'''Sphincter'''
|-
|'''Suprapontine'''
|'''Predominantly storage symptoms'''
|'''Insignificant'''
|
* '''Detrusor overactivity'''
|'''Normal'''
|-
|'''Spinal (infrapontine-suprasacral)'''
|'''Storage and voiding symptoms'''
|'''Usually elevated'''
|
* '''Detrusor overactivity'''
* '''Detrusor sphincter dyssynergia (DSD)'''
* '''Lesions between brainstem and T6 may have autonomic dysreflexia and smooth sphincter dyssynergia'''
|'''Overactive'''
|-
|'''Sacral/infrasacral (below S2)'''
|'''Predominantly voiding symptoms'''
|'''Usually elevated'''
|
* '''Underactive''' (hypocontractile or acontractile) '''detrusor'''
|'''Normal or underactive'''
|}

* '''Lesions above the brainstem (suprapontine)'''
** Typically (with rare exceptions) associated with:
**# Involuntary bladder contractions '''(detrusor overactivity) with'''
**# '''Coordinated sphincter function (smooth and striated sphincter synergy)'''
*** '''Coordinated voiding is regulated by neurologic centers above the spinal cord'''
*** Urinary incontinence may occur owing to the detrusor overactivity
** '''Sensation and voluntary striated sphincter function are usually preserved, but sensation may be deficient or delayed'''
** '''Detrusor areflexia may, however, occur, either initially or as a permanent dysfunction'''
* '''Complete spinal cord lesions'''
** '''After recovering from a period of spinal shock, typically associated with:'''
**# '''Absent sensation'''
**# '''Involuntary bladder contractions (detrusor overactivity)'''
**# '''Smooth sphincter synergy but striated sphincter dyssynergia.'''
**#* A diagnosis of striated/detrusor sphincter dyssynergia (DSD) implies a neurologic lesion that interrupts the neural axis between the pontine-mesencephalic reticular formation and the sacral spinal cord
**#* '''Lesions above spinal cord level T6-T8 (the upper level of the sympathetic outflow) may be associated with smooth sphincter dyssynergia and autonomic hyperreflexia.'''
** '''Incontinence may occur owing to detrusor overactivity; however, the outlet obstruction resulting from striated sphincter dyssynergia can also cause urinary retention and overflow incontinence.'''
* '''Disease below S2 (sacral)'''
** '''Typically associated with:'''
**# '''Lack of involuntary bladder contractions'''
**# '''After the period of spinal shock resolves, persistent detrusor areflexia is the rule.'''
**# Various forms of '''decreased compliance''' during filling (usually resulting from bladder wall fibrosis) may occur and will depend on the type and extent of neurologic insult.
**# '''An open smooth sphincter area may result'''
**#* Whether this is caused by sympathetic or parasympathetic decentralization or defunctionalization (or both or neither) has never been determined.
**# Various types of striated sphincter dysfunction may occur, but '''commonly an injury in this area is associated with a residual/fixed resting striated sphincter tone (not the same as dyssynergia) and striated sphincter activity is not under voluntary control.'''
* '''Interruption of peripheral reflex arc'''
** '''Processes that affect or interrupt the peripheral reflex arc (coordination among spine, bladder, and urethra) may cause storage or emptying dysfunctions that resemble those seen after distal spinal cord or nerve root injury.'''
*** '''Detrusor areflexia often develops, and low compliance may result.'''
*** '''The smooth sphincter may be relatively incompetent, and the striated sphincter may exhibit fixed residual tone that does not voluntarily relax.'''
*** '''True peripheral neuropathy can be motor or sensory, and, at least initially, the usual sequelae can be expected.'''
* See Table 75-1 for Most Common Patterns of Voiding Dysfunction seen with Various Types of Neurogenic Disease or Injury