Detrusor Sphincter Dyssynergia: A Case Study in Integrated Care
and Management Anthony G Bailes AOMA Graduate School of Integrative
Medicine
Slide 2
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
Slide 3
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
Patient Information Demographic Information 60 years old Female
Caucasian Social History Lives alone Unmarried No tobacco No ETOH
No recreational drugs Limited social interaction No
spiritual/religious affiliation
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
Slide 9
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
Slide 10
Slide 11
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
Slide 12
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
Slide 13
June 3, 2014 June 13, 2014 June 16, 2014 August 5, 2014 Follow
Up Visits 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
Slide 14
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
Slide 15
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 (Agr, E. (2013). Percutaneous tibial
nerve stimulation (PTNS) efficacy in the treatment of lower urinary
tract dysfunctions: A systematic review. BMC Urology, 13,
61-61.)
Slide 16
PTNS Protocol Agr, 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
Slide 17
PTNS Protocol Stimulating the tibial nerve by means of a 34
gauge needle electrode 45 cm cephalad to the medial malleolus
Continuous wave at frequency of 20 Hz Stimulation sessions last for
30 minutes Once a week for 1012 weeks Mechanism of action still
remains unclear
Slide 18
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.
Slide 19
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
Slide 20
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.
Slide 21
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
Slide 22
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
Slide 23
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