Numbers:
- Hoeritzauer 2021
- A total of 198 patients presented consecutively over 28 months.
- An alternative neurologic cause of CES emerged in
- 14/198 patients during admission
- 4/151 patients with mean duration 25 months follow-up.
Ways to differentiate
- Scan-negative CES
- More positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative, p < 0.0001),
- Hoover’s sign
- more likely to describe their current back pain as worst ever (41% vs 46% and 70%, p = 0.005),
- more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%, p = 0.001).
- Scan-positive CES
- were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%, p < 0.0001).
- There was no significant difference between groups in the frequency of reduced anal tone and urinary retention.
Causes of scan negative CES
Due to pain, medication and fear
- A.
- In health, bladder filling leads to sacral cord activation and if safe and socially appropriate higher brain centres activate the PAG and voiding occurs.
- B.
- In ‘scan negative’ CES both bladder and brain are affected by medications, pain and fear leading to inhibition of normal voiding, more pain and a negative feedback loop.
- The same brain processes also render individuals susceptible to functional neurological disorder causing motor and sensory dysfunction in the legs
Direct neural inhibition related to pain.
- Pain from nerve root entrapment or muscle spasm → sympathetic hyperactivity + increased inhibitory signals via the pelvic and hypogastric nerves → impeding normal pelvic floor function and parasympathetic urethral sphincter relaxation → difficulty voiding.
- High numbers of patients in the mixed and ‘scan-negative’ CES groups had severe pain caused either by nerve root entrapment or their worst ever back pain.
- These patients also had higher rates of prior chronic pain which may have amplified their pain response through central sensitisation.
Effects of medication.
- Medications such as opiates, tricyclics, benzodiazepines or gabapentinoids can cause urinary incontinence or affect bladder and bowel function causing voiding dysfunction +/- urinary retention
- Over 80% of patients in all groups were on more than one medication which can be associated with urinary retention or urinary incontinence.
Previous bladder dysfunction
- Patients may present with suspected CES due to an exacerbation of their underlying bladder dysfunction from
- Pain
- Panic or
- Medications
- Previous underlying bladder dysfunction
- Stress incontinence
- Overactive bladder syndrome
- Voiding dysfunction
- Stress incontinence is more common in patients with chronic back pain which affected >50% of patients in the mixed and ‘scan-negative’ CES groups.
- medically refractory overactive bladder syndrome symptoms may be due to
- anxiogenic state
- hyperawareness of normal bladder filling
- rather than an abnormality of the detrusor muscle
Shared mechanism with Fowler’s syndrome and Paruresis.
- Paruresis
- Aka “shy bladder syndrome”
- Affects 3-16% of the population
- Causing intermittent inability to initiate or maintain urination.
- Due to
- failure of external urethral sphincter relaxation with inhibitory top-down brain-bladder signals.
- Patients are unable to void when aware of others around them.
- It is usually triggered by an anxiety invoking experience in a toilet,
- is associated with higher than population rates of psychopathology (5-70%)
- Responds to graded exposure therapy.
- Fowler’s syndrome
- Describes chronic urinary retention due to a primary failure of external urethral sphincter relaxation triggered by pain or surgery or medications such as opiates.
- Patients with Fowler’s syndrome have high rates of comorbid functional neurological disorders and pain.
- The aetiology of Fowler’s syndrome is uncertain, but it may be a chronic model of the acute process affecting patients with ‘scan-negative’ CES.
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