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Carvalho Pereira, J.; Pereira, J.; , . Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients. Encyclopedia. Available online: https://encyclopedia.pub/entry/23852 (accessed on 05 December 2025).
Carvalho Pereira J, Pereira J,  . Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients. Encyclopedia. Available at: https://encyclopedia.pub/entry/23852. Accessed December 05, 2025.
Carvalho Pereira, José, José Pereira,  . "Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients" Encyclopedia, https://encyclopedia.pub/entry/23852 (accessed December 05, 2025).
Carvalho Pereira, J., Pereira, J., & , . (2022, June 08). Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients. In Encyclopedia. https://encyclopedia.pub/entry/23852
Carvalho Pereira, José, et al. "Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients." Encyclopedia. Web. 08 June, 2022.
Detrusor Sphincter Dyssynergia in Spinal Cord Injury Patients
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This entry is adapted from the peer-reviewed paper 10.3390/uro2020015

Detrusor sphincter dyssynergia (DSD) is defined as a detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. The most recent International Continence Society (ICS) 2020 Standards define DSD as a dyscoordination between detrusor and rhabdosphincter function during voiding due to a neurological abnormality (i.e., detrusor contraction synchronous with the contraction of the urethral and/or periurethral striated muscle). This is a feature of neurological bladder voiding disorders. DSD generally occurs due to a lesion above the sacral level and below the pons.

spinal cord injury detrusor sphincter dyssynergia urodynamics evaluation

1. Urodynamics Evaluation of DSD in SCI Patients

Urodynamics investigation is the mainstay in evaluating neurogenic bladders, including Detrusor sphincter dyssynergia (DSD), in Spinal Cord Injury (SCI) patients. The researchers should keep in mind that the presence of DSD criteria in the urodynamic testing of a patient with unknown spinal cord pathology should address further investigation of spinal cord involvement [1][2]. At the same time, the examiner should be aware that, during urodynamics, a neurologically intact subject may voluntarily contract the external sphincter during detrusor contractions [3].

1.1. Filling Cystometry/Pressure-Flow Study/Urethral Pressure

Cystometry evaluates the filling and storage phases of detrusor function by measuring changes in the intravesical pressure that occur with increases in bladder volume. The normal adult bladder capacity is around 400–750 mL, with bladder pressure not exceeding 15 cm·H2O during the filling phase. During cystometry, the leak-point pressure (the pressure value at which voiding occurs) is also measured. Whenever this is higher than 40 cm·H2O, which is common in DSD, it indicates a risk of subsequent renal damage [4][5]. Other abnormal cystometry findings in DSD patients include decreased bladder compliance, which is hazardous for the kidneys [4][5].
In the literature about DSD assessment in SCI subjects, the researchers found a diversity of invasive urodynamic setups either with or without a pressure-flow study. While there is unanimity in the measuring method of intravesical pressure [6][7][8], the disagreement was due mainly to the different techniques employed to obtain and measure the signal to study EUS behavior, either with or without bladder neck involvement.

1.2. DSD and BND

Urodynamics with VCUG can evaluate bladder neck dyssynergia (BND) [3][9][10]. Yalla et al. [9] considered that internal sphincter dyssynergia alone in SCI patients is rarely seen. In Schurch et al.’s [10] research, 44 urodynamics studies from 34 out of spinal shock SCI patients (28 men, 6 women) with upper motor neuron bladders were evaluated. Interestingly they were able to investigate BND and DSD, since their urodynamics framework included pressure transducers in the bladder, bladder neck, and membranous/bulbar urethra. They found BND and DSD were both present in almost all patients with complete SCI above T12, and that paraplegics with incomplete lesions had DSD without BND. Furthermore, all tetraplegics, either complete or incomplete, presented with BND associated with autonomic dysreflexia. According to Schurch, active BND was independent of EUS action. BND would occur when there was a disruption of the inhibitory influence of the parasympathetic system on the sympathetic control in the bladder neck. These findings should raise questions when considering treatment options in patients with complete SCI above T12, where interventions aiming only the EUS might fail. Soler et al. [11] retrospectively studied the outcome predictors of EUS botulinum toxin injection as a therapeutic intervention in 99 adults male suprasacral SCI patients with DSD, and they determined that the presence of a BND in VCUG was a predictor of failure for this intervention.

1.3. Ultrasound and Urodynamics

In 1986, when diagnostic ultra-sound technology was in its early stages, Perkash et al. used combined urodynamics and transrectal sonography, which they found instrumental in their understanding of neurogenic voiding dysfunction, as well as the role that DSD plays [12]. In the researchers' PubMed/Medline search, the researchers found only three other articles, all dating back to the 1980s, related to the simultaneous use of urodynamics and transrectal ultrasound [13][14][15]. Shapeero et al. [14] explored the bladder neck and urethra functions of 32 men with suspected bladder neuromuscular dysfunction using transrectal sonography, urodynamic studies, and VCUG. There were 27 coupled transrectal voiding sonography and urodynamic studies with recordings of periurethral EMG, VCUG, and urethral pressure. Shabsigh et al. [15] performed 31 combined transrectal ultrasonographic and urodynamic studies in 24 suprasacral SCI male patients to study specifically DSD. A variety of urodynamic measurements, including bladder pressure, rectal pressure (obtained from the water-filled condom around the ultrasound probe), detrusor (subtraction) pressure, uroflow, and EUS EMG activity were recorded, and this technique was considered useful in evaluating DSD. Both authors [14][15] found a superiority in diagnostic accuracy of sonography when compared with VCUG, with an advantage/drawback trade-off favoring the ultrasound (an absence of irradiation exposure to the patient and examiner, the potential of imaging the periurethral and bladder soft tissue, and a longer duration of image acquisition). Given the paucity of research results found on urodynamics combined with ultrasound imaging techniques, whose technology has improved exponentially, the researchers searched the literature for other possibilities in this field that might be of interest for the instrumental evaluation of DSD in SCI individuals. Contrast-enhanced voiding urosonography (ceVUS) is a well-established ultrasound method used in children for detecting and grading vesicoureteral reflux, as well as for urethral imaging [16][17]. Notwithstanding, since the researchers did not find any publication on contrast-enhanced voiding urosonography coupled with urodynamics, it seems logical that, at least conceptually, this possibility merits dedicated research in evaluating DSD in SCI patients, especially when electronic pressure sensors will be widely available in urodynamics.

1.4. Uroflowmetry, Post Void Residual Volume (PVR) and Bladder Diary

While not specific to DSD, the measurement of the urinary flow rate in an SCI patient with DSD should confirm the presence of bladder outlet obstruction [18]. An intermittent or low flow and the presence of significant PVR in uroflowmetry in a SCI subject is highly suggestive of DSD [19]. In clinical practice, uroflowmetry or important PVR measured by ultrasound, indicating bladder outlet obstruction in an SCI patient, is a noninvasive procedure that should alert the clinician of the likelihood of DSD, fostering further urodynamics investigation. The same argument applies when there is evidence of urine retention in the data from a patient’s bladder or voiding diary, i.e., a daily record of the patient’s bladder functioning which provides an objective documentation of voiding pattern, sensation, volumes (including PVR), incontinence episodes, and events that might lead to an incontinent episode, or urine retention evidence [4]. PVR can also be used as an outcome to appreciate efficacy in DSD treatment [20][21].

2. Other Clinical Dimension in Evaluation of DSD in SCI Patients

2.1. Anamnesis

In SCI patients with DSD, anamnesis should ascertain comorbidities, past medical history, prior surgeries, bowel and sexual function, previous and present management of DSD, bladder emptying method, parenting desire, and factors implied in DSD management, such as prostate enlargement and post-obstetric urethral hypermobility [18][22]. Usual medication must be considered, with special attention paid to the anticholinergic burden, especially when dealing with older SCI patients presenting cognitive impairment either with or without glaucoma [5][23]. Clinicians should inquire for the availability of support, home and work circumstances, lifestyle factors, motivation for treatment, and risk for irritative conditions such as pressure ulcers. [22]. Special attention should be paid to clues of early clinical degradation, such as an aggravation of autonomic dysreflexia clinical pattern (episodes symptoms, duration, frequency, unknown trigger), recurrent urinary tract infections, and worsening signs of urinary retention. These should be kept in view in the therapeutic plan or while evaluating treatment outcomes [5][22]. Quality of life measures are common indicators of therapeutic success for DSD in SCI patients in the literature [20] and are encouraged to be used in clinical practice [22].

2.2. Physical Exam

SCI patients should have routine physical examination, including general neurologic examination, establishing SCI severity with a validated system such as the American Spinal Cord Injury (ASIA) score, (neurologic level and completeness of injury), verifying emergence from spinal shock by disclosure of the sacral metameric reflexes, which coincides with appearance of DSD, and searching for spasticity which is associated with DSD [19][22]. Physical exam should include a perineal examination, voluntary pelvic floor contractions, anal sphincter voluntary contraction and tone, sensation of the sacral dermatomes and testing the sacral reflexes (anocutaneous and respectively the bulbocavernosus and bulboanal in male or the clitoridocavernous, and clitoridoanal in female patients). An evaluation of the prostate is also important in men. Hand function should also be appreciated, expressly to assess the patient’s ability to practice clean intermittent bladder self-catheterization as a voiding method whether indicated; for this purpose, the pencil and paper test could be used [24].

2.3. Complementary Diagnostic and Follow-Up

There are no one-size-fits-all surveillance workup protocols for these patients, but undoubtedly, a clinical frequent follow-up (annually for Corcos et al. [25]) is advised for this population of patients, and should include [4][5][22] the assessment of:
  • renal function:
    ○
    routine: plasma concentration of electrolytes, urea, creatinine (or cystatin C), 24 h creatinine clearance.
    ○
    optional or with special indication: kidney scintigraphy.
  • upper and lower urinary tract structural changes:
    ○
    routine: upper and lower tract transabdominal ultrasound examination with morphometric measures and PVR estimation, screening for lithiasis, bladder trabeculation, and diverticula.
    ○
    optional or with special indication: VCUG, urethro-cystoscopy, transrectal ultrasound for prostate assessment, long term screening of neoplasms.
  • screening for lower urinary tract bacterial colonization. Asymptomatic bacteriuria in these population should not be treated with antibiotics.

2.4. Autonomic Dysreflexia and DSD

Autonomic dysreflexia is an abnormal autonomic reflex responding to nociceptive stimuli below the level of injury, which develops in patients with high-level SCI (usually above T6) and is commonly associated with DSD [10]. A remarkable rise in blood pressure during an autonomic dysreflexia episode sometimes leads to serious complications, such as intracranial hemorrhage and lethal arrhythmias [26][27]. Physicians should remove the causes of the stimuli as soon as possible, and deal with the hypertensive crisis. When DSD is suspected in a patient undergoing invasive urodynamics, an infusion debit of 20 mL/min during cystometry is advised. Furthermore, symptoms and blood pressure should be carefully monitored during examinations that require bladder filling (urodynamics [28], cystoscopy [5]). In SCI with DSD, an aggravation of autonomic dysreflexia should prompt for more DSD aggressive treatment [29].

References

  1. Gross, O.; Leitner, L.; Rasenack, M.; Schubert, M.; Kessler, T.M. Detrusor sphincter dyssynergia: Can a more specific definition distinguish between patients with and without an underlying neurological disorder? Spinal Cord 2021, 59, 1026–1033.
  2. Roy, H.A.; Nettleton, J.; Blain, C.; Dalton, C.; Farhan, B.; Fernandes, A.; Georgopoulos, P.; Klepsch, S.; Lavelle, J.; Martinelli, E.; et al. Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: A report from an International Continence Society consensus working group. Neurourol. Urodyn. 2020, 39, 2535–2543.
  3. Blaivas, J.G.; Sinha, H.P.; Zayed, A.A.; Labib, K.B. Detrusor-external Sphincter Dyssynergia: A Detailed Electromyographic Study. J. Urol. 1981, 125, 545–548.
  4. Ahmed, H.U.; Shergill, I.S.; Arya, M.; Shah, P.J.R. Management of detrusor–external sphincter dyssynergia. Nat. Clin. Pract. Urol. 2006, 3, 368–380.
  5. Sekido, N.; Igawa, Y.; Kakizaki, H.; Kitta, T.; Sengoku, A.; Takahashi, S.; Takahashi, R.; Tanaka, K.; Namima, T.; Honda, M.; et al. Clinical guidelines for the diagnosis and treatment of lower urinary tract dysfunction in patients with spinal cord injury. Int. J. Urol. 2020, 27, 276–288.
  6. D’Ancona, C.; Haylen, B.; Oelke, M.; Abranches-Monteiro, L.; Arnold, E.; Goldman, H.; Hamid, R.; Homma, Y.; Marcelissen, T.; Rademakers, K.; et al. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol. Urodyn. 2019, 38, 433–477.
  7. Rosier, P.F.; Schaefer, W.; Lose, G.; Goldman, H.B.; Guralnick, M.; Eustice, S.; Dickinson, T.; Hashim, H. International Continence Society Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study. Neurourol. Urodyn. 2016, 36, 1243–1260.
  8. Schäfer, W.; Abrams, P.; Liao, L.; Mattiasson, A.; Pesce, F.; Spangberg, A.; Sterling, A.M.; Zinner, N.R.; van Kerrebroeck, P.; International Continence Society. Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Neurourol. Urodyn. 2002, 21, 261–274.
  9. Yalla, S.V.; Blunt, K.J.; Fam, B.A.; Constantinople, N.L.; Gutes, R.F. Detrusor-Urethral Sphincter Dyssynergia. J. Urol. 1977, 118, 1026–1029.
  10. Schurch, B.; Yasuda, K.; Rossier, A.B. Detrusor Bladder Neck Dyssynergia Revisited. J. Urol. 1994, 152 Pt 1, 2066–2070.
  11. Soler, J.M.; Previnaire, J.G.; Hadiji, N. Predictors of outcome for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia in men with spinal cord injury. Spinal Cord 2016, 54, 452–456.
  12. Perkash, I. Physical medicine and rehabilitation: Sonographic urodynamics. West. J. Med. 1986, 144, 736.
  13. Perkash, I.; Friedland, G.W. Catheter-induced hyperreflexia in spinal cord injury patients: Diagnosis by sonographic voiding cystourethrography. Radiology 1986, 159, 453–455.
  14. Shapeero, L.; Friedland, G.; Perkash, I. Transrectal sonographic voiding cystourethrography: Studies in neuromuscular bladder dysfunction. Am. J. Roentgenol. 1983, 141, 83–90.
  15. Shabsigh, R.; Fishman, I.; Krebs, M. Combined Transrectal Ultrasonography and Urodynamics in the Evaluation of Detrusor-sphincter Dyssynergia. Br. J. Urol. 1988, 62, 326–330.
  16. Ntoulia, A.; Pascual, E.A.; Back, S.J.; Bellah, R.D.; Salazar, V.P.B.; Chan, P.K.J.; Chow, J.S.; Robinot, D.C.; Darge, K.; Duran, C.; et al. Contrast-enhanced voiding urosonography, part 1: Vesicoureteral reflux evaluation. Pediatr. Radiol. 2021, 51, 2351–2367.
  17. Barnewolt, C.E.; Acharya, P.T.; Pascual, E.A.; Back, S.J.; Salazar, V.P.B.; Chan, P.K.J.; Chow, J.S.; Robinot, D.C.; Darge, K.; Duran, C.; et al. Contrast-enhanced voiding urosonography part 2: Urethral imaging. Pediatr. Radiol. 2021, 51, 2368–2386.
  18. Amarenco, G.; Ismaël, S.S.; Chesnel, C.; Charlanes, A.; Breton, F.L.E. Diagnosis and clinical evaluation of neurogenic bladder. Eur. J. Phys. Rehabil. Med. 2017, 53, 975–980.
  19. Amarenco, G.; Ismael, S.S.; Soler, J.M. The dyssynergic sphincter. In Textbook of the Neurogenic Bladder; Corcos, J., Ginsberg, D., Karsenty, G., Eds.; CRC Press: Boca Raton, FL, USA, 2016; pp. 133–137.
  20. Chen, C.-Y.; Liao, C.-H.; Kuo, H.-C. Therapeutic effects of detrusor botulinum toxin A injection on neurogenic detrusor overactivity in patients with different levels of spinal cord injury and types of detrusor sphincter dyssynergia. Spinal Cord 2011, 49, 659–664.
  21. Habchi, H.; Galaup, J.-P.; Morel-Journel, N.; Ruffion, A. Toxine botulique A et dyssynergie vésico-sphinctérienne: Étude rétrospective portant sur 47 patients. Prog. Urol. 2014, 24, 234–239. (In French)
  22. Drake, M.J.; Apostolidis, A.; Cocci, A.; Emmanuel, A.; Gajewski, J.B.J.B.; Harrison, S.C.W.S.C.; Heesakkers, J.P.F.J.P.; Lemack, G.G.E.; Madersbacher, H.; Panicker, J.N.J.N.; et al. Neurogenic lower urinary tract dysfunction: Clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013. Neurourol. Urodyn. 2016, 35, 657–665.
  23. Stewart, C.; Gallacher, K.; Nakham, A.; Cruickshank, M.; Newlands, R.; Bond, C.; Myint, P.K.; Bhattacharya, D.; Mair, F.S. Barriers and facilitators to reducing anticholinergic burden: A qualitative systematic review. Int. J. Clin. Pharm. 2021, 43, 1451–1460.
  24. Amarenco, G.; Guinet, A.; Jousse, M.; Verollet, D.; Ismael, S.S. Pencil and Paper Test: A New Tool to Predict the Ability of Neurological Patients to Practice Clean Intermittent Self-Catheterization. J. Urol. 2011, 185, 578–582.
  25. Mahfouz, W.; Corcos, J. Management of detrusor external sphincter dyssynergia in neurogenic bladder. Eur. J. Phys. Rehabil. Med. 2011, 47, 639–650.
  26. Kim, D.-I.; Tan, C.O. Alterations in autonomic cerebrovascular control after spinal cord injury. Auton. Neurosci. 2018, 209, 43–50.
  27. Hou, S.; Rabchevsky, A.G. Autonomic Consequences of Spinal Cord Injury. Compr. Physiol. 2014, 4, 1419–1453.
  28. Perkash, I. Autonomic dysreflexia and detrusor-sphincter dyssynergia in spinal cord injury patients. J. Spinal Cord Med. 1997, 20, 365–370.
  29. Barton, C.H.; Khonsari, F.; Vaziri, N.D.; Byrne, C.; Gordon, S.; Friis, R. The Effect of Modified Transurethral Sphincterotomy on Autonomic Dysreflexia. J. Urol. 1986, 135, 83–85.
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Subjects: Urology & Nephrology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register : José Carvalho Pereira , José Pereira ,
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