Hypothesis / aims of study
Aims of Study: Neural Tube defects occur in 1 in 1000 live births in USA. Preliminary surveys show that the incidence of in India is as high as 4.1 per thousand, presumably due to Folic Acid deficiency, ignorance about the nutrition and poverty(1). A large majority of these patients present with Meningomyelocele. The aim of this study was to determine the common urodynamic patterns that are prevalent in patients of Meningomyelocele in this part of the world. Other objectives were to identify the factors that pose risks to the upper urinary tracts in these patients(2). Secondary aim was to determine the prevalent pattern of tertiary referral in terms of age of these patients.
Study design, materials and methods
Materials and Methods: 153 cases presented by referral for Urodynamic Investigations within 7 years (From 1st August 2011 to 31st July 2018). Medical and Social Interrogation was performed on all patients. Complete physical and neurological examination was performed for abnormalities in the lower limbs. Focused neurological examination for the Sacral Reflex Arc was carried out on all patients. All cases underwent complete Urodynamic evaluation with EMG. Videourodynamic investigation was performed only where this was specifically requested. Detrusor Leak Point Pressure (DLPP) was estimated on all patients using a 6F double lumen catheter. Attempted voiding study was performed using 6F bilumen catheter in a position that the patients were used to void.
Results : Age of presentation for first Urodynamic evaluation also makes this unique in India. Among 153 cases, only 80 patients presented before the age of 10 years, while 58 cases presented between the ages of 10 and 25 years.
Urinary Incontinence was the commonest presenting symptom among these patients. (121 out of 153). Other common symptoms of presentation were difficulty in emtying, recurrent urinary tract infections and urinary retention. Associated bowel symptoms were common.
Abnormalities in the lower limbs was seen in 55 of the total number of 153 patients (35.9%).
60 patients had DLPP less than 40 cms. of H2O leaving 73 patients having DLPP of 40 cms. or more. On only 84 of all patients, the information of Ultrasound assessment of upper urinary tracts was available. According to our data, out of 46 patients with DLPP higher than 40 cms., 33 patients had a demonstrable upper tract dilatation (71.7%), whereas upper tract dilatation was also seen in 12 patients out of 38, in whom DLPP ranged between 20 and 40 cms. of H2O. (31.5%)
Interpretation of results
The commonest Urodynamic pattens were
1. Poor Detrusor Compliance + Detrusor Underactivity + Nonrelaxing Sphincter Obstruction in 70 patients (45.7%)
2. Poor Detrusor Compliance + Detrusor Underactivity + Normal Sphincter Function in 24 patients (15.6%) and
3. Poor Detrusor Compliance + Pelvic Floor Denervation with sphincter incompetence in 11 patients (7.1%)
The incidence of Neural Tube Defects and Meningomyelocele in India is believed to be among the highest in the world. Besides, the age of presentation for a tertiary urological management also appears to be very high for various social and economic reasons. Although Urinary Incontinenece is the commonest symptom of presentation, lower limb abnormalities and bowel dysfunction are also common in this group.
Detrusor hypocompliance, detrusor underactivity and nonrelaxing distal sphincter obstruction leading to a significant voiding inefficiency are the commonest Urodynamic features. Detrusor Leak Point Pressures of 20 cms. of H2O and above appear to have a significant effect on the structure of the upper urinary tracts and on the overall renal function. Along with the assocoaited bowel dysfunction this condition adds a significant load on the Medical fraternity, practicing Functional Urology in India.
Key Words : Incontinence, Neuropathies : Central, Detrusor Overactivity, Underactive Bladder, Voiding Dysfunction