Michael J. Amirian, MD
Patrick J. Shenot, MD, FACS
BASICS
DESCRIPTION
• Detrusor sphincter dyssynergia (DSD) is found in cases of neurogenic lower urinary tract dysfunction
• DSD is contraction of the sphincter mechanism occurring simultaneously with uninhibited involuntary contraction of the bladder detrusor muscle (neurogenic detrusor overactivity [NDO])
EPIDEMIOLOGY
Incidence
• Unknown
– Depends on incidence of underlying neurologic condition
Prevalence
• Prevalent in those with spinal cord lesions
– More prevalent at higher levels (cervical) than lower (sacral) injury or disease
• May affect those with multiple sclerosis (MS), spinal cord tumor, traumatic spinal cord injury (SCI), arteriovenous malformation
• Uninhibited involuntary detrusor contraction (ie, NDO) must be present for DSD to occur
RISK FACTORS
• Neurologic processes affecting central nervous system (CNS)
– Below level of the pons
• Associated with autonomic hyperreflexia
Genetics
None
PATHOPHYSIOLOGY
• DSD causes functional outflow obstruction
– Dramatic elevation of intravesical pressure
Damages urinary tract directly with pressure and poor upper tract drainage
Secondarily with infection and urolithiasis
• DSD always associated with NDO
– NDO may occur with synergic sphincter function (without DSD)
• Pontine mesencephalic reticular formation
– Coordinates sphincter relaxation with detrusor contraction
Spinal cord lesions impair transmission of coordinating influences from the pons during reflex detrusor contraction
Uninhibited detrusor contraction stimulates a reflex sphincter contraction, resulting in bladder outflow obstruction
• 10–20% patients have internal (bladder neck) sphincter dyssynergia coexistent with external sphincter dyssynergia
ASSOCIATED CONDITIONS
• SCI
• MS
• Transverse myelitis
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Neurologic disease
– Date of onset, duration of process
• Urinary voiding symptoms
– Frequency, urgency, urge incontinence
• Method of urinary management
– Condom catheter urinary collection
– Intermittent self-catheterization
– Indwelling urethral or suprapubic catheter
• Urinary tract infection (UTI)
– Severity of infection
Response to antibiotics
Need for parenteral antibiotics
– Frequency of occurrence of infection
– Urolithiasis
Episodes of lithiasis
Surgical intervention
PHYSICAL EXAM
• Fever
• Parenchymal UTI
– Men
Prostate, testes/epididymis, renal
– Female
Renal
• Hypertension
– During manipulation of GI/GU systems, autonomic hyperreflexia may result
• Generalized edema
– Severe renal insufficiency
• Palpable flank mass
– Secondary hydronephrosis
• Flank tenderness
– Ureteral obstruction
– Pyelonephritis
• Abdominal mass
– Distended bladder, urinary retention
• Incontinence of urine
– Spontaneously
– With stress maneuvers
– During abdominal/pelvic palpation
• Testicular mass
– Epididymo-orchitis/epididymitis
– Secondary abscess formation
– Hydrocele from recurrent infection
• Prostate mass/nodule
– Focal prostatitis
– Prostate abscess
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Blood studies
– Serum chemistry
Renal function, electrolyte levels
– Complete blood count
Secondary anemia due to decreased renal function or chronic infection
• Urine studies
– Urinalysis
Proteinuria: Renal dysfunction
Pyuria, nitrite, leukocyte esterase: Acute or chronic infection
Hematuria: Infection or lithiasis
Imaging
• Renal ultrasound (US)
– Effective in screening for upper urinary tracts
Calculus
Hydronephrosis
Masses
• Excretory urography (ExU)
– Contraindicated in those with decreased renal function (serum creatinine >2.0)
– Delayed excretion of contract with high urinary storage pressures
– Hydroureteronephrosis
Marked elevation of intravesical pressure
May be due to urinary calculi
• Voiding cystourethrogram
– Bladder
Wall thickening
Trabeculation
Diverticulum formation
Incomplete emptying
– Ureter
Vesicoureteral reflux
Hydroureter
Hydroureteronephrosis
– Urethra
Prostatic urethral dilated
Membranous urethra persistently narrow, stenotic, nonrelaxing
Distal urethra normal; rule out stricture
• Nuclear medicine renal scan
– Objective quantification of GFR
– Sequential studies can detect deterioration of renal function prior to elevation of serum creatinine
Diagnostic Procedures/Surgery
• Urodynamic evaluation
– Essential to diagnose detrusor overactivity with detrusor sphincter dyssynergy
• Cystoscopy
– Normal penile urethral
– Spastic, nonrelaxing, stenotic membranous urethral
– Dilated prostatic urethra
– Bladder trabeculation/diverticula
– Rule out calculus or bladder tumor
Pathologic Findings
None
DIFFERENTIAL DIAGNOSIS
• Detrusor overactivity and bladder outflow obstruction
– Benign prostatic hyperplasia
– Adenocarcinoma of the prostate
– Urethral stricture disease
– Urethral tumor
• Urinary retention/incomplete emptying and neurologic disease
– Impaired detrusor contractility
– Detrusor areflexia
TREATMENT
GENERAL MEASURES
• Intermittent catheterization
• Decrease intravesical pressure
– Decrease bladder contractility
Low-pressure urinary storage
– Defeat sphincter function to establish low-pressure urinary drainage per urethra
Only option for males
No effective external urinary collection device for females
MEDICATION
First Line
• Anticholinergic therapy
– Effective in improving urinary storage under low pressure
Hyoscyamine 0.375 mg PO BID-TID
Oxybutynin 5 mg PO TID-QID
Oxybutynin extended release 5–40 mg/d PO
Tolterodine 2–4 mg PO BID
• α-Adrenergic blockade
– Decrease internal sphincter function
– Largely ineffective for external sphincter dyssynergia
Alfuzosin 10 mg/d PO
Phenoxybenzamine 10 mg PO BID (nonselective)
Terazosin 2–5 mg PO daily-BID
Doxazosin 2–8 mg/d PO
Tamsulosin 0.4 mg PO daily
Second Line
• Botulinum toxin injection into the external sphincter for DSD
– Short lived
– Requires repeated injections (1)[B]
SURGERY/OTHER PROCEDURES
• Endoscopic sphincter ablation
– Only in males as it requires condom catheter urinary collection
Electrosurgical or laser sphincterotomy: Incise external sphincter from bulbous urethra to midprostatic urethra
Further incision through the prostate and bladder neck may be required if internal dyssynergia is present
• Sphincter stent prosthesis placement
– Wire mesh stent placed endoscopically
– Bridges midprostatic to bulbous urethra (2)[A]
Maintains caliber of membranous urethra at 42 French
Suprapubic tube cystostomy may be required in perioperative period
• Augmentation cystoplasty
– Bladder is incised in clamshell fashion to disrupt detrusor contraction
– Gastrointestinal segment used to enlarge bladder, increasing urinary storage with decreased pressure
May use large intestine, ileum, or gastric segment
Requires intermittent catheterization for urinary drainage
Limited dexterity may mandate creation of continent catheterizable stoma for the urinary reservoir, especially in females
• Ileal conduit cutaneous vesicostomy
– Conduit of ileum connecting dome of bladder to anterior abdominal wall
Continuous low-pressure drainage through incontinent ileal conduit urostomy requires stomal appliance for urinary collection
Useful for those who cannot perform self-catheterization (ie, quadriplegia)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Sacral deafferentation with sacral nerve root stimulation
– Deafferentation with dorsal rhizotomy abolishes spontaneous detrusor contraction, improving urinary storage
– Nerve root stimulation allows control over detrusor contraction
– Obstruction by sphincter may require adjunctive sphincteric ablation
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Excellent prognosis if effectively treated
• Untreated, ∼50% of men will develop significant complication
COMPLICATIONS
• Vesicoureteral reflux
• Renal insufficiency
• Urolithiasis
• Urosepsis
FOLLOW-UP
Patient Monitoring
• Annual evaluation
– Urodynamic testing
Assure low intravesical pressure
– Upper tract imaging (Ultrasound most comonly used; decreasing reliance on excretory urogram)
Rule out upper tract changes (calculi, hydroneprhosis)
• Serum chemistry
– Confirm normal renal function and electrolyte balance
Patient Resources
N/A
REFERENCES
1. Schurch B, Hauri D, Rodic B, et al. Botulinum-A toxin as treatment of detrusor sphincter dyssynergia: A prospective study in 24 spinal cord injury patients. J Urol. 1996;155:1023–1029.
2. Chancellor M, Gajewski J, Ackman CF, et al. Long-term follow-up of the North American Multicenter UroLume Trial for the treatment of external detrusor-sphincter dyssynergia. J Urol. 1999;161:1545–1550.
ADDITIONAL READING
• Blaivas JG. The neurophysiology of micturition: A clinical study of 550 patients. J Urol. 1982;127:958–964.
• Consortium for Spinal Cord Medicine. Bladder management for adults with spinal cord injury: A clinical practice guideline for health care providers. Available at http://www.nxtbook.com/nxtbooks/pva/bladdermanagement/index.php, Accessed April 2013.
• Fowler C. Neurological disorders of micturition and their treatment. Brain. 1999;146:1213–1231.
• Kaplan SA, Chancellor MB, Blaivas JG. Bladder and sphincter behavior in patients with spinal cord lesions. J Urol. 1991;146:113–117.
See Also (Topic, Algorithm, Media)
• Detrusor-Sphincter Dyssynergia (DSD) Image 
• Guillain–Barré Syndrome (Transverse Myelitis), Urologic Considerations
• Multiple Sclerosis, Urologic Considerations
• Spinal Cord Injury, Urologic Considerations
• Urodynamics, Indications and Normal Values
CODES
ICD9
• 596.0 Bladder neck obstruction
• 596.54 Neurogenic bladder NOS
• 596.55 Detrusor sphincter dyssynergia
ICD10
• N31.8 Other neuromuscular dysfunction of bladder
• N31.9 Neuromuscular dysfunction of bladder, unspecified
• N36.44 Muscular disorders of urethra
CLINICAL/SURGICAL PEARLS
• DSD is always associated with NDO.
• Anticholinergic therapy and α-Adrenergic blockade are 1st-line medical therapy.
• If left untreated, ∼50% of men will develop significant complication.