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Date of last update: 8/13/2017.

Forum Name: Urology Topics

Question: Treatment options for Detrusor Sphinctor Dyssynergia

 emergentmind - Thu Dec 10, 2009 9:26 am

I've been diagnosed with severe Detrusor External Sphinctor Dyssynergia last year, and have been receiving botox injections into the sphinctor. It was confirmed with video urodynamics, and the bladder pressures were extremely high (over 200 cm). I also have a stricture near the tip of my penis which is extremely sensitive, so much so that I cannot self-cath, and have to go under general anesthesia for any cystoscopies or other procedures. I also have frequent pain in the kidneys, probably from the high bladder pressures, and I'll be getting an ultrasound soon to look for damage. Finally I also have an overactive bladder (also trabeculated), causing frequent urge incontinence, as well as frequent dribbling. I do not have any known spinal injuries, or MS, and my symptoms began in 2001 from being beaten severely in a fight.

My concern is that I do not want to continue the botox treatments forever, because they do not last very long, and eventually my body will develop antibodies to it, and I want a second opinion on other possible treatments. My urologist insists that I get an interstim installed, and if that fails, get a tube sticking out of my belly to drain urine. Neither of these options are acceptable for me, because the interstim is not MRI compatible, and my work in clinical research requires me to be near FMRI frequently, and I just cannot stand the idea of having a tube coming out of my stomach.

I've asked my doctor about getting a urolume stent installed since they are MRI safe, or even a sphinctorectomy, because honestly I would prefer incontinence to a tube sticking out of me. However, my doctor tells me that stents are only for spinal injuries, yet did not seem to be well informed about them. Also, while I have found information linking interstim to bladder problems, I have not found any information that it relieves sphincter dyssynergia. Ultimately I believe that my sphincter is causing the bladder problems, so treating the bladder without treating the sphincter seems like a disaster. A second opinion would be much appreciated.
 Dr.M.Aroon kamath - Sun Dec 13, 2009 1:48 am

User avatar Hi,
Damage to the nervous system (between the brain-stem and the sacral segments of the spinal cord) can create a lack of coordination between the bladder and the external sphincter muscle, which is the muscle that controls the emptying of the urinary bladder.

As a result, the urinary bladder isn't able to empty completely, which creates a buildup of abnormally high urinary pressures. Detrusor-External Sphincter Dyssynergia (DESD) is a combination of these two factors and thus can lead to serious urinary tract damage and at times, life-threatening consequences.

I hope that 'pseudodyssynergia' has been confidentally ruled out (although it is more common in women).This can only be confidentally diagnosed by concomitant recording of intra-abdominal pressures during study of bladder pressures.

The other complicating factor in your case is the severe meatal stricture.This will undoubtedly continue to increase the bladder pressures even if the DESD is successfully treated.

The mainstay of treatment in is the use of antimuscarinic medication and catheterization (this is obviously not feasible in your case).

Sacral nerve stimulation has been tried (but is ruled out in your case by you).

Botulinum toxin injection (has been tried in your case and obviously, you don't want to continue with it).

Thus, the two major remaining choices for you are...

a) Stents: migration, urethral erosion, erectile dysfunction or encrustatios are known complications.Also, introduction of the stent itself may not be straightforward in your case.

b) External sphincterotomy, however, is associated with significant risks which include erectile dysfunction, hemorrhage, and the need for repeat procedures.

Therefore you have to make a serious choice in consultation with your urologist as to which modality is best suited for you.
Best wishes!

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