Autonomic hyperreflexia

1. 1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. Innervation of Vesicourethral Unit
 Involves all three divisions of peripheral nervous
system
 Detrusor – pelvic nerves – parasympathetic nerves –
S2,3,4
 Hypogastric nerves – sympathetic nerves – T10-12 –
bladder neck and urethral smooth muscles
 Pudendal nerves – somatic – pelvic floor and external
sphincter.
3
Dept of Urology, GRH and KMC, Chennai.

4. Central control
 Micturition reflex – hierarchic
 Centres located in cerebrum, hypothalamus, mid
brain, pons, spinalcord
 Pontine centre – coordinates detrusor and sphincter
activity
 Suprapontine – inhibitory effect over lower centres
4
Dept of Urology, GRH and KMC, Chennai.

5. Tracts in spinal cord
 Anterior horn-motor,
 Lateral horn- visceral afferent and efferent.
 Posterior horn- sensory.
DESCENDING TRACTS
1)Pyramidal or corticospinal tract.
2)Extra pyramidal tracts
rubrospinal,olivospinal,vesciculospinal,tectospinal,med
and lateral reticulospinal.
5
Dept of Urology, GRH and KMC, Chennai.

6. ASCENDING TRACTS
Lateral spinothalamic tract
Anterior spinothalmic tract
Fasciculus gracilis
Fasciculus cuneatus
Dorsal spino cerebellar tract
ventral spino cerebellar tract
Spino olivary tract
Spinotectal tract
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Dept of Urology, GRH and KMC, Chennai.

7. Spinal cord injury(SCI)
 Due to violence, fracture, dislocation of spinal column
– accidents ,
 fall,
 vascular injury,
 disc prolapse,
 severe, sudden hyper extension from other causes
 Lower urinary tract and sexual function – affected
 Uti, sepsis, stone disease , autonomic hyper reflexia,
depression occurs
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Dept of Urology, GRH and KMC, Chennai.

8. Spinal cord injury(SCI)
 MALE-82%, Children – 3 to 5%
 Age – 31.5 years
 MC-motor vehicle accident-45%
- lesion occurs at or above T12 level –mostly involved.
- mostly incomplete quadriplegics
- leading cause of death – pneumonia, septicemia,
suicide
8
Dept of Urology, GRH and KMC, Chennai.

9. FRANKEL CLASSIFICATION
 A)COMPLETE-no motor or sensory function below
level of lesion.
 B)INCOMPLETE- minimal sensory preservation
 C) INCOMPLETE – minimal motor preservation
 D) INCOMPLETE – Motor preservation with muscle
power < 3
 E) NORMAL
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Dept of Urology, GRH and KMC, Chennai.

10. Spinal shock
 Acute phase - decreased excitability of spinal segment
at and below the lesion
 Absent somatic reflex activity and flaccid muscle
paralysis below, generally - areflexia
 In complete SCI – 6 to 12 weeks,may last for 1 to 2 years
 In incomplete SCI shorter period of time
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Dept of Urology, GRH and KMC, Chennai.

11.  includes supression of autonomic activity, somatic
activity and bladder is acontractile, areflexic
 smooth muscle sphincter –functional,
 striated sphincter-some EMG activity.
 guarding reflex is absent and no voluntary control.
 urinary retention is the rule.
 overflow incontinence occurs.
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Dept of Urology, GRH and KMC, Chennai.

12. SUPRA SACRAL SPINAL CORD INJURY
 The characteristic pattern - detrusor overactivity,
smooth sphincter synergia (with lesions below the
sympathetic outflow), and striated sphincter
dyssynergia
 Neurologic examination - spasticity of skeletal muscle
distal to the lesion, hyperreflexic deep tendon reflexes,
and abnormal plantar responses.
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Dept of Urology, GRH and KMC, Chennai.

13. SACRAL SCI
- varying degrees of flaccid paralysis. Sensation is
generally absent below the lesion level.
- Detrusor areflexia with high or normal compliance
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Dept of Urology, GRH and KMC, Chennai.

14. Effects of neurological lesion
 Complete transection - rare
 - vary with level, extent of injury
 Cerebrum – involuntary detrusor contractions –
coordinated sphincter
 Frontalcortex, internal capsule – detrusor hyper
reflexia with coordinated or uninhibited sphincter
 Urinary incontinence
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Dept of Urology, GRH and KMC, Chennai.

15. High spinal cord Injury
 High spinal cord – C1 to C8
 vesico sphincter dyssynergia
 Detrusor hyper reflexia,
 external sphincter dyssynergia
 Vesico urethral unit separated from pontine control
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Dept of Urology, GRH and KMC, Chennai.

16. Low spinalcord Injury
 Low spinalcord injury T1-L5
 paraplegia,
 detrusor hyper reflexia,
 sphincter dyssynergia
16
Dept of Urology, GRH and KMC, Chennai.

17. Sacral spinal cord Injury
 Sacral spinal cord – S1-S5
 detrusor paralysis,
 denervated pelvic floor,
 incompetent bladder neck
 More prone for incontinence
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Dept of Urology, GRH and KMC, Chennai.

18. AUTONOMIC HYPERREFLEXIA
-Guttman & Whitteridge-1947
also called Autonomic dysreflexia
 fatal emergency – unique to SCI patient
 Autonomic hyperreflexia represents an acute massive
disordered autonomic (primarily sympathetic) response to
specific stimuli in patients with SCI above the cord level of
T6 to T8 .
 It is more common in cervical (60%) than thoracic (20%)
injuries.
 Onset-usually soon after spinal shock but may be up to
years after injury.
 Distal cord viability is a prerequisite.
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Dept of Urology, GRH and KMC, Chennai.

19.  Clinically – syndrome of exaggerated sympathetic
activity in response to stimuli below the level of lesion
 Symptoms – pounding headache,
 varying degrees of hypertension,
 flushing of face and body above the level of lesion,
sweating ,
 bradycardia / tachycardia / arrythmia
19
Dept of Urology, GRH and KMC, Chennai.

20.  STIMULI – bladder, rectum
 Generally due to distension, or other stimuli may
precipitate like
 Lower urinary tract instrumentation
 Catheter change
 Catheter obstruction
 Clot retention
 Urinary tract calculi
 GI pathalogy long bone fracture , electro coagulation
 Sexual activity
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Dept of Urology, GRH and KMC, Chennai.

21. PATHOPHYSIOLOGY
 Any nociceptive stimulation via afferent impluses that
ascend through the cord and elicit reflex motor out
flow causing arteriolar, pilomotor and pelvic visceral
spasm and sweating.
 Normally reflexes are inhibited by medulla
 Striated sphincter dyssynergia
 Smooth sphincter dyssynergia
21
Dept of Urology, GRH and KMC, Chennai.

22. Management
 Ideally any endoscopic procedure in susceptible
patients should be done – spinal or general
anesthesia.
 Acute hemodynamic effects – alpha blocker, beta
blocker, or combined
 Previously ganglion blockers were used
 Sublingual nifedipine – widely used
 Controversial results
 During cystoscopy – 10 to 20mg, or 30 min before
 Before electro coagulation – 20mg nifedipine 30min
before
22
Dept of Urology, GRH and KMC, Chennai.

23.  Anasthetist suggests labetolol.
 Other drugs used are captopril, hydralazine, diazoxide
 Long term prophylactic drugs
 Terazosin – 1 to 10 mg
 Erectile function and blood pressure are minimally
changed
 prazosin
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Dept of Urology, GRH and KMC, Chennai.

24. In severe and intractable dysreflexia following
neuro-ablative procedures are done :
- sympathectomy
- sacral neurectomy
- sacral rhizotomy with CIC
- cordectomy
- dorsal root ganglionectomy
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Dept of Urology, GRH and KMC, Chennai.