Detrusor hyperreflexia. A survey on its etiology and treatment

Detrusor hyperreflexia (DH) is a frequently occurring condition. The symptomatology is characterized by frequency, urgency and urge incontinence. DH is defined as involuntary, uninhibited detrusor contractions. The physiology and pathophysiology of the micturition reflex is reviewed. The balance between cerebral stimulation and supraspinal inhibition is discussed. DH is caused by disturbances in this balance. Whereas increased afferent impulses to the central nervous system due to local disorders in bladder and/or urethra may produce DH, a neurological disorder affecting the inhibitory nervous pathways from cortical and subcortical centres always result in uninhibited detrusor contractions. DH was found in 25% of 2000 patients. In the majority of the patients the DH was caused by a neurological disorder. The incidence of DH in patients with enuresis, gynecological patients with urinary incontinence and/or genital prolapse and patients with benign prostatic hyperplasia (BPH) is reported. In 62% of the patients with BPH the DH was eliminated after adequate surgical treatment of the infravesical obstruction. By contrast, DH in women with genital prolapse and/or incontinence persisted despite operative treatment. In a retrospective investigation of 152 patients with DH, the cause of the DH was unknown in 32 patients (21%). A clinical neurological examination revealed no evidence of neurological disease in 45% of the 22 patients examined. Voiding symptoms were the only complaint in these patients as well as in 30-40% of the patients in the other groups mentioned. This calls for improved investigatory methods in the evaluation of the balance between stimulation and inhibition of the micturition reflex. The presence of uninhibited detrusor contractions in apparently healthy patients should indicate a neurological examination since DH may be the first sign of a neurological disorder. The micturition reflex is conducted through long, uninterrupted neurons with a marked central integration. Therefore cystometry may be used as a supplement to the clinical neurological examination in the early diagnosis of pyramidal or extrapyramidal central nervous system disorders.