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Structure and Function of the Lower Urinary Tract
Published in Anthony R. Mundy, John M. Fitzpatrick, David E. Neal, Nicholas J. R. George, The Scientific Basis of Urology, 2010
There is the simple hydrokinetic observation that there is only actually one way out of the bladder and that is through the bladder neck, so that when the detrusor contracts, the force is likely to be transmitted in that direction (Fig. 40). It may well be that this simplistic point of view is at least in part correct, perhaps in conjunction with the reciprocal relaxation theory modified to incorporate the action of nitric oxide rather than the sympathetic nervous system. In addition, it should be noted that it has been observed in spinal cord-injured patients fitted with a sacral anterior root stimulator that the bladder neck can be made to open and close separately from events in the main body of the detrusor, indicating that there may be a separate innervation to the bladder neck (Giles Brindley, personal communication). Clearly, as it can only be demonstrated in this way and then only under certain circumstances and in some patients, this innervation cannot readily be dissected out from innervation of the bladder as a whole, but again it would tend to support the reciprocal innervation theory, with the corelease of nitric oxide in the sphincter-active area to explain opening coincident with cholinergic-mediated detrusor contraction.
Restoration of complete bladder function by neurostimulation
Published in Jacques Corcos, David Ginsberg, Gilles Karsenty, Textbook of the Neurogenic Bladder, 2015
In the 1970s, Brindley7 developed an implantable device to empty the bladder and control the sphincters. The prosthesis uses SARS (Finetech–Brindley SARS; Finetech Medical Limited, Welwyn Garden City, United Kingdom) to activate bladder motor pathways and to produce clinically effective voiding (Figure 53.2). For reflex incontinence and sphincter dyssynergia to be overcome in these patients, the sacral sensory nerve roots from S2 to S4 have to be cut (sacral deafferentation or posterior rhizotomy).8 The device consists of electrodes, which can be placed intrathecally or extradurally (the deafferentation is usually performed intradurally as it is easier to separate the nerves at this level). Cables are tunneled subcutaneously to a receiver block, which is placed on the chest wall. The device is activated through radio frequency coupling using a transmitter block aligned over the receiver. An external control box is programmed by the clinician to activate the efferent pathways to the bladder. As the sacral anterior roots S2–S4 innervate both the bladder and sphincters, an implant-induced dyssynergia is produced. This is overcome by using the differential properties of smooth and striated muscles of the bladder and sphincters. By using short bursts of stimulation, poststimulus voiding occurs in gaps between stimulation, although not physiological this gives extremely efficient voiding with low residuals. The sacral anterior root stimulator can also be used to aid bowel evacuation and produce implant-driven erections in males. The same nerves that innervate the bladder also innervate the lower part of the colon and the rectum. This stimulation can facilitate movement of stool into the rectum as well as evacuating the rectum in approximately 50% of patients. Even if some degree of manual evacuation is still required, the whole process of bowel emptying has been shown to be decreased to a significant degree by the use of the stimulator.
Digital rectal stimulation as an intervention in persons with spinal cord injury and upper motor neuron neurogenic bowel. An evidenced-based systematic review of the literature
Published in The Journal of Spinal Cord Medicine, 2021
Mary Elizabeth S. Nelson, Merle Orr
Quality of life: Four studies examined QOL as a primary outcome, while three additional studies looked at episodes of incontinence as a primary outcome of interest, which could be correlated with satisfaction and QOL given the goal of promotion of bowel evacuation at a set time and schedule to promote QOL. Both the studies with a quality A grade incorporated QOL as an outcome, either directly or through evaluation of incontinence. Ayas et al.7 looked at episodes of incontinence and found a significant decrease in episodes of incontinence after abdominal massage, suggesting an improvement in QOL rating. Valles et al.14 looked at QOL as a primary outcome. Satisfaction with the bowel program was noted to improve after implant of a sacral anterior root stimulator, which related to increased QOL. Christensen et al.'s12 study on transanal irrigation (Level I evidence) utilized two validated tools to correlate improve QOL with transanal irrigation. The lack of control exhibited by the concurrent use of other means of bowel evacuation did not take from the strength of the evidence provided. Del Popolo et al.13 also examined the effect of transanal irrigation on QOL. They found intervention significantly improved QOL to a P = 0.001 level with the primary limitation to the study being lack of long-term follow up of patients after treatment.