Download Detrusor Sphincter Dyssynergia: A Case Study in Integrated Care

Detrusor Sphincter Dyssynergia:
A Case Study in Integrated Care and
Management
Anthony G Bailes
AOMA Graduate School of Integrative Medicine
Detrusor Sphincter Dyssynergia (DSD)
• Bladder Sphincter Dyssynergia
• Voiding dysfunction
• symptoms related to both the storage and emptying
phases of the micturition cycle
• Storage dysfunction
• Emptying dysfunction
DSD
Detrusor muscle
• The detrusor muscle remains
relaxed to allow the bladder to
store urine
• Contracts during urination to
release urine
External sphincter muscle of
urethra
• Efferent muscle
• Receives innervation form the
pudendal nerve
Voiding Dysfunction
Emptying Dysfunction
Storage Dysfunction
• Frequency
• Urgency
• Urge incontinence
• Dysuria
• Pain
• Hesitancy
• Straining
• Difficulty initiating
• Diminished stream
• Incomplete voiding
• Urinary retention
Patient Information
Social History
Demographic Information
• 60 years old
• Female
• Caucasian
• Lives alone
• Unmarried
• No tobacco
• No ETOH
• No recreational drugs
• Limited social interaction
• No spiritual/religious affiliation
Medications/Supplements
Dietary Habits
• Insulin
• Aspirin prn
• Magnesium glycinate 300mg QD
• Multivitamins
• Gluten free
• Low sugar
• Includes animal proteins
Exercise
Allergies
• Sulfas
• Floroquinolone (Cipro)
• Walking to tolerance
• Physical therapy
Medical Hx
• Contracted Hep C in 1982 form surgical blood transfusion
• Was not diagnosed until 2008
• Treated with Copegus (ribavirin) and Alinia (nitazoxanide)
• Treated for 1 yr w/resolution of sustained virologic response
• Diagnosed Type I Diabetes in 2009
• Thought to be a result of undiagnosed/untreated Hep C
• Managed w/insulin
Surgical Hx
• 1982: T8 to S1 fusion to correct scoliosis
• February 2014: T8 to S1 fusion to correct long standing complications
from 1982 surgery
• December 2013, presented in ER with complaints of severe pain
• Internal hemorrhaging, spontaneous cerebrospinal fluid leak, and atrial
fibrillation
• Resulted in 10 hospitalization
• During corrective surgery, the pudendal and hypogastric afferent nerves
around the bladder were damaged, resulting in DSD
May 5, 2014 – Initial office visit
• Vitals within normal ranges
• CC: urinary difficulty with dribbling, urgency, and retention
• Urgency up to 20 times daily, difficulty initiating urination, interrupted urine flow,
and inability to void completely
• Recurrent urinary tract infections UTIs
• Self-cath three times daily
• Secondary complaint: Depression
• Tegretol 200mg BID and Prozac 20 mg QD
• Self-discontinued Prozac and Tegretol after 1 month, citing the “inability to function”
• Tertiary Complaint: R sided sciatic pattern pain rating 8/10
• Confirmed with seated straight leg raise
• DDX: Qi blockage in Bladder Channel and Organ
• TX: Unblock channel and organ Qi
• Points: SP 6, 9; Ren 2, 3, 4; ST 36; Yintang, Kidney
Gate; BL 23, 27, 28, 39, 52; (R) GB 30, 42; (R) BL 60,
61, 63; (Bilateral) Ashi around PSIS (4 needles) and
Ashi lateral hip (1 needle); All points with strong
manual manipulation.
• Herbs: (patent – unspecified) Shao Yao Gan Cao Tang;
2 pills TID
Follow Up Visits
•June 3, 2014
•June 13, 2014
•June 16, 2014
•August 5, 2014
• No significant changes other than
reduction in sciatic pain to manageable
levels. Initial tx resulted in full bladder
evacuation for 1 day, but returned to old
pattern. During this period, patient had
multiple UTIs and was dx w/Kidney
infection.
• Antibiotics resolved infection and patient
began prophylactic Hiprex (methenamine
hippurate) to manage UTIs
• No remarkable changes to DSD
August 12, 2014
• DSD symptoms still persisting
• Outside research found study on pudendal nerve
stimulation for DSD and voiding disorders
• Percutaneous Tibial Nerve Stimulation (PTNS) protocol
• 12 treatments and reevaluate
• Points: BL 14, 15, 18, 23, 28, 40, 65; PTNS Protocol
• Herbs: (patents) Plum Flower Ba Zheng San – 8 pills TID; Plum Flower
Jia Wei Xiao Yao San – 8 pills TID
• Notes: Patient was instructed to take herbs concurrently with
antibiotics.
• **PTNS Protocol: Electro acupuncture at SP 5 to SP 6 bilaterally.
Stimulated with continuous wave at 20 Hz for 30 minutes
(Agrò, E. (2013). Percutaneous tibial nerve stimulation (PTNS) efficacy in the treatment of lower urinary tract
dysfunctions: A systematic review. BMC Urology, 13, 61-61.)
PTNS Protocol
Agrò, E. (2013). Percutaneous tibial nerve stimulation (PTNS) efficacy in
the treatment of lower urinary tract dysfunctions: A systematic review.
BMC Urology, 13, 61-61.
• 2013 Italy
• PTNS was found to be effective in 37-100% of patients with overactive
bladder syndrome (OAB)
• 41-100% of patients with non-obstructive urinary retention (NOUR)
• 100% of patients with chronic pelvic pain/painful bladder syndrome
(CPP/PBS), dysfunctional voiding and patients with neurogenic
pathologies
• No major complications have been reported
PTNS Protocol
• Stimulating the tibial nerve by means of a 34 gauge needle
electrode
• 4–5 cm cephalad to the medial malleolus
• Continuous wave at frequency of 20 Hz
• Stimulation sessions last for 30 minutes
• Once a week for 10–12 weeks
• Mechanism of action still remains unclear
August 14, 2014
• Patient reports more complete evacuation after last
treatment.
• Easier to initiate urination.
• Patient reports increased energy, improved bowel
movements, and increased appetite.
• Patient reports numbness in vaginal wall.
• Points: BL 14, 18, 23, 24, 25, 26, 40, 65; Four Gates;
KD 7; Jiaji L2 through S1; PTNS Protocol
• Herbs: (patents) Plum Flower Ba Zheng San – 8 pills 5X
a day; Plum Flower Zhi Bai Di Huang Wan – 8 pills TID
August 19, 2014
• Patient reports she has been evacuating bladder 100%, verified by
urologist with imaging.
• Urologist dismissed patient and has taken her off self-catheterization.
• No UTI for first time in 7 months.
• Numbness in R lower leg, R anterior upper leg, pelvic floor, and
vaginal wall.
• Although mood has improved, patient is still worried that results are
only temporary and is feeling “emotional”.
• Points: BL 13, 23, 24, 25, 26, 40; GB 41; Four Gates;
Jiaji L4 through S4; (R) PTNS Protocol
• Herbs: Continue current Plum Flower Ba Zheng San –
8 pills TID; Plum Flower Jia Wei Xiao Yao San – 8 pills
TID
• August 21, 2014 – dx with Interstitial Cystitis
• August 28, 2014
• September 1, 2014 – IC controlled with dietary changes
• September 4, 2014
• September 9, 2014 – IC resolved, but new dx of UTI.
Antibiotics prescribed
• September 15, 2014
• September 23, 2014 – IC resolved
• September 29, 2014
• October 7, 2014 – UTI cleared
October 21, 2014
• No UTIs since early September
• Bladder function maintaining normal with complete
evacuation
• Emotions stabilized
• Patient wishes to consider support for increasing libido and
addressing mild vaginal dryness
• No other complaints
• Patient will schedule follow up treatments as needed
Thank You
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