Radiology Teaching Files > Case 311523

Contributed by: Children's Hospital Omaha, Radiologist, Omaha Childrens, Creighton University and UNMC, Nebraska, USA.
Patient: 8 year old male
History: 8-year-old hispanic male with history of repaired myelomeningocele with Chiari II malformation and shunted hydrocephalus presenting with incontinence and recurrent UTI.

Fig. 1: AP view VCUG Pre-void image with contrast-filled, small, trabeculated bladder

Fig. 2: Oblique view VCUG image showing intermittent involuntary dribbling with significant residual

Fig. 3: Lateral view dynamic VCUG showing distended proximal urethra with reflux into mildly dilated ejaculatory ducts

Fig. 4: Oblique view VCUG Post catheter drainage
Findings: The bladder was slowly filled with 150 cc Hypaque 30%. At maximal distention, frontal view (Figure 1) demonstrates a small, trabeculated bladder with "Christmas tree" appearance. No evidence of vesicoureteral reflux. The patient then involuntarily intermittently dribbled 30 cc contrast with a large post-void residual (Figure 2). Dynamic lateral view shows a distended proximal urethra with reflux into mildly dilated ejaculatory ducts (Figure 3). Finally, the bladder was drained via catheter, extracting the remaining 120 cc of contrast (Figure 4).
Diagnosis: Neurogenic Bladder- Detrusor/External Sphincter Dyssynergia

Neurogenic Bladder with Hyperactive Detrusor

- Caused by upper motor neuron lesion in the detrusor inhibitory pathway resulting in involutary bladder contractions
- Most common neuropathic bladder disorder
- Causes include trauma, stroke, neoplasm, abscess, and congenital or neurodegenerative disorders
- Two major types:
1- Hyperactive detrusor with external sphincter coordination: lesion above the pons; involuntary detrusor contraction coordinated with external sphincter relaxation; results in incontinence with negligible post-void residual
2- Hyperactive detrusor with external sphincter dyssynergia- lesion below the pons; detrusor involuntarily contracts against a hyperactive contracted external sphincter resulting in high intravesical pressure; when pressure overcomes external sphincter contraction, results in incontinence with moderate to high post-void residual
- Complications include vesicoureteral reflux, UTI and urolithiasis
- Other imaging modalities include functional retrograde urethrogram in males and videodynamic evaluation

References: "Principles of Genitourinary Radiology", 2nd edition. Barbaric, Z.L. Thieme Medical Publishers, copyright 1994, pp. 400-403.
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Additional Details:

Case Number: 311523Last Updated: 11-20-2004
Anatomy: Genitourinary (GU)   Pathology: Congenital
Modality: GUExam Date: 01-29-2004Access Level: Readable by all users
Keywords: neurogenic bladder, detrusor/external sphincter dyssenergia, hyperactive detrusor, hyperreflexic detrusor, reflex neurogenic bladder, upper motor neuron lesion bladder

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