• Patients in the acute phase of the GB syn- drome should be managed expectantly, the indwelling catheter being the treatment of choice (Grade C)
• No extensive diagnostics of the bladder/ure- thral functions are needed during the acute phase (Grade C)
• During and after the recovery of the paraly- sis a detailed functional evaluation of the LUT in symptomatic patients is needed in order to optimize the therapy (Grade C)
Conclusions
• In the acute phase of GB syndrome about 25% of patients demonstrate LUT functio- nal problems (LOE3)
• Both storage and voiding symptoms are observed in GB syndrome (LOE 3)
• Recovery of the LUT functions might take months and sometimes a full recovery is not possible (LOE 3)
IV. GUIDELINES FOR FURTHER
RESEARCH
III. DISEASE SPECIFIC DIAGNOSIS
AND TREATMENTI
3) described a higher prevalence of incontinence in HIV-positive patients in nursing homes as compared to HIV-negative. Gyrtrup et al [3] (LOE 3) found voiding problems in 12% of HIV-infected patients, mostly in an advanced stage of the disease.
As already described virtually all parts of the LUT innervation can be involved in AIDS patients, either as the primary location of HIV infection or seconda- ry to HIV-related complications. Among these diffe- rent manifestations particular attention should be paid to the primary locations as they develop early in the stage of the disease.
HTLV-I associated myelopathy (HAM) affects up to 3% of HIV positive patients and is manifested by slowly progressive spastic paraparesis, including deterioration of bladder problems [4] (LOE 2). Ano- ther primary demonstration of HIV infection is lum- bosacral polyradiculopathy, described by Matsumoto et al (LOE 3) [5]. In this case report voiding difficul- ties and lower limb paresis were the primary mani- festation of HIV infection.
Also Mahieux et al [6]( LOE 3) described a case of acute myeloradiculitis due to cytomegalovirus as the initial manifestation of the terminal stage.
Begara et al [7] (LOE 3) performed urodynamic stu- dies in 10 patients with AIDS and voiding disorders and found that the most common symptom was urge incontinence and the most common urodynamic fin- ding was detrusor-external sphincter dyssynergia. In 3 patients they found demonstrable functional disor- ders of the LUT (2 patients had detrusor overactivi- ty: one of them had a history of encephalopathy from HIV and the other patient had polyneuritis; the third patient had myelitis and a urodynamically diagnosed sympathetic decentralization). Detrusor areflexia was described in 2 HIV-positive patients by Menen- dez et al [8](LOE 3). One of them had an ascending myelitis of probable herpetic origin; the other had a cerebral abscess caused by Toxoplasma gondii.
Since during the course of the disease all parts of the nervous system can be involved, either as the prima- ry location or secondary to AIDS-related complica-
tions, no disease specific diagnosis or treatment can be proposed. It is important to observe that some- times functional disorders of the LUT can be the first manifestation of the HIV infection.
When managing the patient with HIV infection one must bear in mind that both storage and voiding pro- blems can occur and that both should be treated according to the results of urodynamic studies.
All rapports about HIV and voiding problems are rather anecdotal, and no good prospective studies exist. The need for such studies is particularly important, when realizing that it takes up to 20-30 years from HIV infection to AIDS full manifestation and that new anti- viral treatment modalities could prolong the life of a patient with HIV significantly. Particular attention should be paid to primary nervous system involvement by HIV and to related voiding dysfunction.
Recommendations
• Patients with HIV related nervous system pathological signs and symptoms should be evaluated for functional LUT problems (Grade C)
• Due to the variety of LUT functional dama- ge in AIDS patients urodynamic study is essential for tailoring the optimal therapy (Grade C)
Conclusions
• HIV can influence the nervous system and the LUT functions in two ways: as primary infection or secondary to AIDS related com- plications (LOE 3)
• Nervous system manifestation of HIV infec- tion can by the only sign, and it is therefore important to take the possibility of HIV infection into consideration when facing unu- sual signs and symptoms from the LUT without any other obvious cause (LOE 3) • AIDS is a progressive disease, and dynamic
changes to the LUT functions can occur during the evolution of the disease (LOE 3)
IV. GUIDELINES FOR FURTHER
RESEARCH
III. DISEASE SPECIFIC DIAGNOSIS
AND TREATMENT
II. PATHOLOGY AND DISEASE
SPECIFIC LUT PROBLEMS
Usually disc prolapse is in a posterolateral direction which does not affect the majority of the cauda equi- na. Bartolin et al [1] reported normal detrusor activi- ty in 83/114 patients with lumbar disc protrusion. Cauda equina syndrome due to central lumbar disc prolapse has been reported to be relatively rare, the incidence being from 1 to 5% of all prolapsed lum- bar discs [2 – 9].
Central lumbar disc prolapse can compress sacral nerve fibers to and from the bladder, the large bowel, the anal and urethral sphincters, and pelvic floor. Cli- nical features of the cauda equina syndrome include low-back pain, bilateral sciatica, saddle anesthesia, and urinary retention, loss of urethral sensation as well as constipation and erectile dysfunction [5, 8, 10, 11] (LOE 3). Those patients with cauda equina syndrome usually have some sensory disturbance in the sacral dermatomes [5, 11] (LOE 3). Disturbed afferent activity from the bladder can be present.
The most common urinary symptom associated with lumbar disc prolapse is acute urinary retention [12] (LOE 3). At the onset, acontractile detrusor with impaired bladder sensation is a typical urodynamic finding [5, 11, 12] (LOE 3). Severe denervation of pelvic floor [12] and external urethral sphincter [11] is also frequently demonstrated. Detrusor overactivi- ty may occur, presumably through the irritation of the sacral nerve root [12]. Urinary disorders usually follow or accompany more obvious neurologic symptoms, such as lumbar pain and perineal sensory disturbances, which lead to a proper diagnosis. However, sometimes voiding disturbances may be the only or the first symptom of this condition, which makes it more difficult to diagnose this disease [4, 10] (LOE3).
Emergency surgical decompression has been repor- ted to be important to increase the chance of satis- factory neurological recovery in patients with cauda equina syndrome due to central lumbar disc prolapse [5, 13 – 15](LOE3). In a meta-analysis of surgical outcomes, Ahn et al [8] reported that a significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent the surgery within 48 hours compared with those who had the surgery more than 48 hours after the onset of the cauda equina syndrome. Also other reports support the concept that decompression performed within 48 hours of onset of this syndrome resulted in improved functional outcomes [4, 9, 16] (LOE 3). However, acontractile detrusor is usually irreversible even after immediate decompression [10, 1, 17] (LOE 3). Although most patients can empty their bladder postoperatively, it is only by straining or changing their voiding postures [11, 17]. In contrast to bladder dysfunction, urethral function shows a better recovery after surgery [11 – 12] (LOE 3).
Please refer to the chapter on children. We reviewed only the scarce literature on adult patients.
Myelomeningocele (spina bifida) is one of the most common birth defects of the spine and brain. It occurs in 1-2 births per 1000, involving all levels of the spinal column (lumbar 26%, lumbosacral 47%,