Prof. Dr. med. Thomas M. Kessler
Neuro-Urology is a young and dynamic subspecialty of urology, with a rapidly expanding knowledge base and huge treatment success in recent years. It contributes to a considerable increase in life-expectancy following a spinal cord injury.
Neuro-Urology arose in the 1970s from the urological rehabilitation of patients with paraplegia and tetraplegia (classic examples) and addresses disorders of the urinary tract and sex organs following damage to the nerve supply.
We diagnose and treat:
- Functional bladder disorders
- Functional sphincter disorders
- Disorders of sexual function
- Ejaculation disorders
- Functional intestinal disorders
- Urogenital pain syndromes
Patients come to us with:
- Traumatic spinal cord injuries
- Following operations on the spine or spinal cord
- Diseases of the spinal cord
- Tumours of the spinal cord
- Congenital malformations of the spinal cord (e.g. spina bifida)
- Multiple sclerosis
- Parkinson’s disease
- Following traumatic brain injuries (head injuries)
- Cerebrovascular disease (e.g. stroke)
- Bladder, intestinal and sexual dysfunction following pelvic surgery
- Functional bladder disorders of unknown origin
- Pain in the urogenital area
The initial discussion allows the patient and the doctor to get to know each other and build up a relationship of trust; it is the starting point for the subsequent work-up/investigations and therefore absolutely essential for successful treatment.
You will be asked to keep a bladder diary over a period of three to four days to record the quantity of fluid you drink, the amount of urine you pass, episodes of urgency, leakage of urine, the number of incontinence pads you need, and any pain you experience. The diary reflects the day-to-day situation and helps us to understand your problems. A carefully completed bladder diary is also a basis for successful treatment.
Urine tests can indicate or rule out a urinary tract infection. In addition, urine tests can also suggest other diseases, such as bladder cancer or diabetes, that require further investigation.
Clinical examination allows the examiner to detect abnormal changes and instigate further work-up/investigations and treatment on the basis of the findings. The examination includes the abdomen, genital area, pelvic floor and anus, a rectal examination, and palpation of the prostate gland in men.
Urine flow tests
To measure the urine released from the body (uroflowmetry), you will be asked to urinate into a specially designed toilet. This will measure and record the volume of urine and the speed with which it is released. The amount of urine that remains in the bladder (residual urine) will then be determined with an ultrasound scan or by passing a catheter into the bladder. The flow curve and the volume of residual urine provide important information on the cause of your problems.
Ultrasound scanning (also called ultrasonography or simply sonography) is an imaging technique that does not expose you to radiation. It is therefore used in neuro-urology to examine the kidneys, bladder, testes and epididymis, and the prostate gland.
Endoscopy of the urethra and bladder
Endoscopy of the urethra and bladder (urethrocystoscopy) involves an optical instrument being inserted into the urethra and advanced as far as the bladder. This instrument (called a cystoscope) allows the examiner to look at the inside of the urethra and bladder. Scars, stones, tumours, inflammation and other abnormal changes can be identified directly. Depending on the situation, the examiner may use a rigid or a flexible scope. As a rule, the examination is performed under a local anaesthetic and does not cause any more discomfort than a bladder catheter. The examination can be followed on a monitor.
Urodynamic testing looks at the function of the urinary tract. A fine measuring catheter is inserted into the bladder (usually through the urethra but sometimes through the abdominal wall) and a second catheter inserted into the rectum. Electrodes are attached to the pelvic floor. Under image guidance, the bladder is filled with saline solution via the measuring catheter. The pressures in the bladder and the abdominal cavity are recorded, as well as the activity of the pelvic floor, to assess urinary tract function during filling and emptying the bladder. In order to detect changes in the shape of the bladder or any return flow (reflux) into the ureters or even the kidneys, the bladder is filled with a mixture of saline and contrast medium for video-urodynamics. The cardiovascular system is monitored so that any abnormal changes in blood pressure or heart rate while the bladder is being filled can be recognised and treated promptly.
When ejaculation is not possible in the natural way, stimulation of the glans of the penis with a special vibrator (vibrostimulation) causes ejaculation in many patients and a semen sample can be obtained.
Should vibrostimulation fail, transrectal electroejaculation is often successful in obtaining a semen sample. An electrode placed in the anus is stimulated. As this procedure is painful, it is performed under a general anaesthetic unless the patient has a complete spinal cord injury (transrectal electroejaculation can then be carried out without an anaesthetic).
After targeted investigation, we can prescribe appropriate medication for many disorders of the bladder and bowels, sexual dysfunction, or pelvic pain.
If too much urine remains in the bladder after you have urinated, the bladder can be emptied completely by means of a catheter. There is a choice between in-and-out catheterisation (self-catheterisation performed by the patient or intermittently by a third party) and an indwelling catheter via the urethra (transurethral catheter) or through the abdominal wall (suprapubic catheter). In-and-out catheterisation is preferred to an indwelling catheter whenever possible.
Pelvic floor exercises
Regular pelvic floor exercises can contribute considerably to alleviating symptoms of bladder and bowel disorders, as well as relieving pelvic pain.
Neuromodulation (electrical stimulation) has a positive effect on organ malfunction by stimulating spinal cord reflexes and nerve centres in the brain. This offers a therapeutic approach to disorders of the bladder and bowels, sexual dysfunction, and pelvic pain. Stimulation can be applied in the vagina, in the rectum, to the penis (TENS), via the tibial nerve (TTNS, PTNS) or via the nerve roots of the sacrum (sacral neuromodulation)
Botulinum A toxin (Botox) injections
Botulinum A is the most potent naturally occurring toxin and has been used successfully in the treatment of overactive bladders and urge incontinence for many years. After a regional anaesthetic, an optical instrument (cystoscope) is inserted into the bladder via the urethra. A very fine needle inserted through the working channel of the cystoscope is used to inject botulinum A toxin (Botox) into the bladder muscle at 10-30 different sites. An overactive bladder is ‘calmed down’ for about 9-12 months. Treatment can be repeated if the symptoms recur.
Surgery for stress incontinence
If pelvic floor exercises and medication fail to bring about a significant improvement in urine loss when coughing, sneezing, laughing or during physical exercise, the problem may be helped by inserting a synthetic tape beneath the urethra or implanting an artificial sphincter.
Transurethral resection of the prostate (TURP)
A transurethral resection of the prostate (TURP) consists of inserting an optical instrument into the urethra and ‘shelling out’ the prostate gland from the inside, using an electrical loop and high-frequency current. This procedure improves the flow of urine.
Open prostate surgery (adenoma enucleation)
When the prostate is very big, it may be preferable to perform an open operation to ‘shell out’ the gland. A small incision is made in the lower abdomen. The bladder is opened through this incision and the enlarged parts of the prostate removed with the surgeon’s fingers.
One possible treatment for prostate cancer is the complete removal of the prostate (a radical prostatectomy). The entire prostate gland is removed together with the seminal vesicles and associated lymph nodes.
Transurethral resection of the bladder (TURB)
When unexplained changes are seen in the bladder, the abnormal area can be removed through an optical instrument (cystoscope) using an electrical loop and high-frequency current – a procedure called transurethral resection of the bladder (TURB).
Removal of bladder stones
Stones tend to form in the bladder when the outward flow of urine is impeded. Stone formation is also encouraged by the presence of a foreign body such as an indwelling catheter. The optical instrument (cystoscope) is inserted via the urethra and, if necessary, a special instrument is used to reduce the stones in size before they are removed.
Bladder augmentation (enlarging the bladder with small intestine)
If medication, electrical stimulation, and botulinum A toxin injections have all failed, bladder augmentation may be required. A piece of the patient’s own small intestine is sewn into the bladder to increase its volume and lower the pressure that is putting the kidneys at risk. Following this procedure, the bladder is usually emptied by intermittent self-catheterisation.
We are always happy to make an assessment for a second opinion. You can make an appointment with our administrative staff (+41 44 386 39 12). All medical reports that have been issued elsewhere should be sent to our administrative staff before the appointment.
Expert opinion and reports
We are always happy to issue an expert report. We can supply a cost estimate after seeing the medical records and will then determine a cost ceiling with the client.
Prof. Dr. med. Thomas M. Kessler
PD Dr. med. Ulrich Mehnert
Dr. med. Lorenz Leitner
Pract. med. Miriam Koschorke