Current Bladder Dysfunction Reports

, Volume 13, Issue 4, pp 206–214 | Cite as

Contemporary Treatment of Detrusor Sphincter Dyssynergia: a Systematic Review

  • Hanhan Li
  • Nickolas Nahm
  • Alex Borchert
  • Philip Wong
  • Humphrey AtiemoEmail author
Neurogenic Bladder (C Powell, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Neurogenic Bladder


Purpose of Review

To systematically review the literature to determine outcomes of detrusor sphincter dyssynergia (DSD) treatments. DSD can present in patients with neurogenic bladder due to a variety of conditions, but no treatment guidelines currently exist. Ovid Medline, Embase, PubMed, and Web of Science were searched within the last 10 years for “detrusor sphincter dyssynergia.” Results were independently reviewed by two coauthors for inclusion using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA) guidelines. Exclusion criteria were pediatric populations, reviews, non-clinical focus, non-English language, and case reports.

Recent Findings

There were 515 articles screened to yield 21 full text articles. Fourteen were retrospective studies, five were prospective non-randomized studies, and two were prospective, randomized trials. A total of 830 patients (527 male, 104 female, and 199 not specified) had DSD from spinal cord injury (413), multiple sclerosis (104), multiple system atrophy (33), and not specified (280). Treatments included botulinum A injections into the external sphincter (seven studies, reported success rates = 64–100%) or bladder (three studies, 44–76%), urethral stents (four studies, 9–91%), sphincterotomy (two studies, 48–85%), transurethral incision of the bladder neck (one study, 82%), pharmacologic therapy (three studies, 44–76%), sacral neuromodulation (one study, 60%), and anal stretch (one study).


Evaluation of treatment outcomes for DSD is lacking. If conservative therapy fails, botulinum toxin type A injection appears to be a primary intervention strategy. More invasive treatments such as sacral neuromodulation and transurethral incision of the bladder neck also demonstrated high success rates, while urethral stenting was associated with high complication and failure rates.


Detrusor sphincter dyssynergia Neurogenic bladder Bladder outlet obstruction 


Compliance with Ethical Standards

Conflict of Interest

Hanhan Li, Nickolas Nahm, Alex Borchert, Philip Wong, and Humphrey Atiemo declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Supplementary material

11884_2018_482_MOESM1_ESM.docx (14 kb)
Supplementary Table 1 Pharmacologic therapy for treatment of DSD (DOCX 14.2 kb)
11884_2018_482_MOESM2_ESM.docx (14 kb)
Supplementary Table 2 Detrusor botulinum injection for treatment of DSD (DOCX 13.9 kb)
11884_2018_482_MOESM3_ESM.docx (16 kb)
Supplementary Table 3 Urethral botulinum injection for treatment of DSD (DOCX 15.7 kb)


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Blaivas JG, Sinha HP, Zayed AA, Labib KB. Detrusor-external sphincter dyssynergia: a detailed electromyographic study. J Urol. 1981;125(4):545–8.PubMedGoogle Scholar
  2. 2.
    Andersen JT, Bradley WE. The syndrome of detrusor-sphincter dyssynergia. J Urol. 1976;116(4):493–5.PubMedGoogle Scholar
  3. 3.
    Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–78.PubMedGoogle Scholar
  4. 4.
    Blaivas JG. The neurophysiology of micturition: a clinical study of 550 patients. J Urol. 1982;127(5):958–63.PubMedGoogle Scholar
  5. 5.
    Blaivas JG, Barbalias GA. Detrusor-external sphincter dyssynergia in men with multiple sclerosis: an ominous urologic condition. J Urol. 1984;131(1):91–4.PubMedGoogle Scholar
  6. 6.
    Blaivas JG, Sinha HP, Zayed AA, Labib KB. Detrusor-external sphincter dyssynergia. J Urol. 1981;125(4):542–4.PubMedGoogle Scholar
  7. 7.
    Kirby R, Fowler C, Gosling J, Bannister R. Urethro-vesical dysfunction in progressive autonomic failure with multiple system atrophy. J Neurol Neurosurg Psychiatry. 1986;49(5):554–62.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Bacsu CD, Chan L, Tse V. Diagnosing detrusor sphincter dyssynergia in the neurological patient. BJU Int. 2012;109(Suppl 3):31–4.PubMedGoogle Scholar
  9. 9.
    Gerridzen RG, Thijssen AM, Dehoux E. Risk factors for upper tract deterioration in chronic spinal cord injury patients. J Urol. 1992;147(2):416–8.PubMedGoogle Scholar
  10. 10.
    Perkash I. Transurethral sphincterotomy. J Urol. 2009;181(4):1539–40.PubMedGoogle Scholar
  11. 11.
    Ahmed HU, Shergill IS, Arya M, Shah PJ. Management of detrusor-external sphincter dyssynergia. Nat Clin Pract Urol. 2006;3(7):368–80.PubMedGoogle Scholar
  12. 12.
    Dmochowski RR, Ganabathi K, Leach GE. Non-operative management of the urinary tract in spinal cord injury. Neurourol Urodyn. 1995;14(1):47–55.PubMedGoogle Scholar
  13. 13.
    Kim YH, Bird ET, Priebe M, Boone TB. The role of oxybutynin in spinal cord injured patients with indwelling catheters. J Urol. 1997;158(6):2083–6.PubMedGoogle Scholar
  14. 14.
    Yamanishi T, Chapple CR, Chess-Williams R. Which muscarinic receptor is important in the bladder? World J Urol. 2001;19(5):299–306.PubMedGoogle Scholar
  15. 15.
    Hambleton P. Clostridium botulinum toxins: a general review of involvement in disease, structure, mode of action and preparation for clinical use. J Neurol. 1992;239(1):16–20.PubMedGoogle Scholar
  16. 16.
    Schurch B, Stohrer M, Kramer G, Schmid DM, Gaul G, Hauri D. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol. 2000;164(3 Pt 1):692–7.PubMedGoogle Scholar
  17. 17.
    Schurch B, Hauri D, Rodic B, Curt A, Meyer M, Rossier AB. Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients. J Urol. 1996;155(3):1023–9.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Dykstra DD, Sidi AA, Scott AB, Pagel JM, Goldish GD. Effects of botulinum A toxin on detrusor-sphincter dyssynergia in spinal cord injury patients. J Urol. 1988;139(5):919–22.PubMedGoogle Scholar
  19. 19.
    Ross JC, Damanski M, Gibbon N. Resection of the external urethral sphincter in the paraplegic; preliminary report. J Urol. 1958;79(4):742–6.PubMedGoogle Scholar
  20. 20.
    Hamid R, Arya M, Patel HR, Shah PJ. The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up. BJU Int. 2003;91(1):51–3.PubMedGoogle Scholar
  21. 21.
    Catz A, Luttwak ZP, Agranov E, Ronen J, Shpaser R, Paz A, et al. The role of external sphincterotomy for patients with a spinal cord lesion. Spinal Cord. 1997;35(1):48–52.PubMedGoogle Scholar
  22. 22.
    Milroy EJ, Chapple CR, Cooper JE, Eldin A, Wallsten H, Seddon AM, et al. A new treatment for urethral strictures. Lancet. 1988;1(8600):1424–7.PubMedGoogle Scholar
  23. 23.
    Wilson TS, Lemack GE, Dmochowski RR. UroLume stents: lessons learned. J Urol. 2002;167(6):2477–80.PubMedGoogle Scholar
  24. 24.
    Soni BM, Vaidyanatham S, Krishnan KR. Use of Memokath, a second generation urethral stent for relief of urinary retention in male spinal cord injured patients. Paraplegia. 1994;32(7):480–8.PubMedGoogle Scholar
  25. 25.
    Weld KJ, Wall BM, Mangold TA, Steere EL, Dmochowski RR. Influences on renal function in chronic spinal cord injured patients. J Urol. 2000;164(5):1490–3.PubMedGoogle Scholar
  26. 26.
    Yalla SV, Blunt KJ, Fam BA, Constantinople NL, Gittes RF. Detrusor-urethral sphincter dyssynergia. J Urol. 1977;118(6):1026–9.PubMedGoogle Scholar
  27. 27.
    Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349:g7647.Google Scholar
  28. 28.
    Huang YH, Chen SL, Tsai SJ, Bih LI, Lew HL. Urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia. Arch Phys Med Rehabil. 2008;89(9):1748–52.PubMedGoogle Scholar
  29. 29.
    Ito T, Sakakibara R, Yasuda K, Yamamoto T, Uchiyama T, Liu Z, et al. Incomplete emptying and urinary retention in multiple-system atrophy: when does it occur and how do we manage it? Mov Disord. 2006;21(6):816–23.PubMedGoogle Scholar
  30. 30.
    Kilicarslan H, Ayan S, Vuruskan H, Gokce G, Gultekin EY. Treatment of detrusor sphincter dyssynergia with baclofen and doxazosin. Int Urol Nephrol. 2006;38(3–4):537–41.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Nardulli R, Losavio E, Ranieri M, Fiore P, Megna G, Bellomo RG, et al. Combined antimuscarinics for treatment of neurogenic overactive bladder. Int J Immunopathol Pharmacol. 2012;25(1 Suppl):35S–41S.PubMedGoogle Scholar
  32. 32.
    Kuo HC. Therapeutic satisfaction and dissatisfaction in patients with spinal cord lesions and detrusor sphincter dyssynergia who received detrusor botulinum toxin A injection. Urology. 2008;72(5):1056–60.PubMedGoogle Scholar
  33. 33.
    Chen CY, Liao CH, Kuo HC. Therapeutic effects of detrusor botulinum toxin A injection on neurogenic detrusor overactivity in patients with different levels of spinal cord injury and types of detrusor sphincter dyssynergia. Spinal Cord. 2011;49(5):659–64.PubMedGoogle Scholar
  34. 34.
    Kuo HC. Therapeutic outcome and quality of life between urethral and detrusor botulinum toxin treatment for patients with spinal cord lesions and detrusor sphincter dyssynergia. Int J Clin Pract. 2013;67(10):1044–9.PubMedGoogle Scholar
  35. 35.
    Gallien P, Reymann JM, Amarenco G, Nicolas B, de Seze M, Bellissant E. Placebo controlled, randomised, double blind study of the effects of botulinum A toxin on detrusor sphincter dyssynergia in multiple sclerosis patients. J Neurol Neurosurg Psychiatry. 2005;76(12):1670–6.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Liao YM, Kuo HC. Causes of failed urethral botulinum toxin A treatment for emptying failure. Urology. 2007;70(4):763–6.PubMedGoogle Scholar
  37. 37.
    Chen SL, Bih LI, Huang YH, Tsai SJ, Lin TB, Kao YL. Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury. J Rehabil Med. 2008;40(9):744–8.PubMedGoogle Scholar
  38. 38.
    Tsai SJ, Ying TH, Huang YH, Cheng JW, Bih LI, Lew HL. Transperineal injection of botulinum toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance. Arch Phys Med Rehabil. 2009;90(5):832–6.PubMedGoogle Scholar
  39. 39.
    Chen SL, Bih LI, Chen GD, Huang YH, You YH. Comparing a transrectal ultrasound-guided with a cystoscopy-guided botulinum toxin a injection in treating detrusor external sphincter dyssynergia in spinal cord injury. Am J Phys Med Rehabil. 2011;90(9):723–30.PubMedGoogle Scholar
  40. 40.
    • Yang WX, Zhu HJ, Chen WG, Zhang DW, Su M, Feng JF, et al. Treatment of detrusor external sphincter dyssynergia using ultrasound-guided trocar catheter transurethral botulinum toxin a injection in men with spinal cord injury. Arch Phys Med Rehabil. 2015;96(4):614–9. This recent paper describes using botox treatment for DSD in patients with spinal cord injury. PubMedGoogle Scholar
  41. 41.
    Mehta SS, Tophill PR. Memokath stents for the treatment of detrusor sphincter dyssynergia (DSD) in men with spinal cord injury: the Princess Royal Spinal Injuries Unit 10-year experience. Spinal Cord. 2006;44(1):1–6.PubMedGoogle Scholar
  42. 42.
    Seoane-Rodriguez S, Sanchez RLJ, Montoto-Marques A, Salvador-de la Barrera S, Ferreiro-Velasco ME, Alvarez-Castelo L, et al. Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia. Spinal Cord. 2007;45(9):621–6.PubMedGoogle Scholar
  43. 43.
    Game X, Chartier-Kastler E, Ayoub N, Even-Schneider A, Richard F, Denys P. Outcome after treatment of detrusor-sphincter dyssynergia by temporary stent. Spinal Cord. 2008;46(1):74–7.PubMedGoogle Scholar
  44. 44.
    Abdul-Rahman A, Ismail S, Hamid R, Shah J. A 20-year follow-up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury. BJU Int. 2010;106(10):1510–3.PubMedGoogle Scholar
  45. 45.
    Minardi D, Muzzonigro G. Sacral neuromodulation in patients with multiple sclerosis. World J Urol. 2012;30(1):123–8.PubMedGoogle Scholar
  46. 46.
    Pan D, Troy A, Rogerson J, Bolton D, Brown D, Lawrentschuk N. Long-term outcomes of external sphincterotomy in a spinal injured population. J Urol. 2009;181(2):705–9.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Pannek J, Hilfiker R, Goecking K, Bersch U. Preoperative urodynamic assessment in patients with spinal cord lesions undergoing sphincterotomy: is success predictable? Urol Int. 2009;83(4):386–91.PubMedGoogle Scholar
  48. 48.
    Ke QS, Kuo HC. Transurethral incision of the bladder neck to treat bladder neck dysfunction and voiding dysfunction in patients with high-level spinal cord injuries. Neurourol Urodyn. 2010;29(5):748–52.PubMedGoogle Scholar
  49. 49.
    Lindehall B, Abrahamsson K, Hjalmas K, Jodal U, Olsson I, Sillen U. Complications of clean intermittent catheterization in boys and young males with neurogenic bladder dysfunction. J Urol. 2004;172(4 Pt 2):1686–8.PubMedGoogle Scholar
  50. 50.
    Wyndaele JJ. Complications of intermittent catheterization: their prevention and treatment. Spinal Cord. 2002;40(10):536–41.PubMedGoogle Scholar
  51. 51.
    Hollingsworth JM, Rogers MA, Krein SL, Hickner A, Kuhn L, Cheng A, et al. Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis. Ann Intern Med. 2013;159(6):401–10.PubMedGoogle Scholar
  52. 52.
    de Seze M, Petit H, Gallien P, de Seze MP, Joseph PA, Mazaux JM, et al. Botulinum A toxin and detrusor sphincter dyssynergia: a double-blind lidocaine-controlled study in 13 patients with spinal cord disease. Eur Urol. 2002;42(1):56–62.PubMedGoogle Scholar
  53. 53.
    Chancellor MB, Gajewski J, Ackman CF, Appell RA, Bennett J, Binard J, et al. Long-term follow-up of the North American multicenter UroLume trial for the treatment of external detrusor-sphincter dyssynergia. J Urol. 1999;161(5):1545–50.PubMedGoogle Scholar
  54. 54.
    Fontaine E, Hajri M, Rhein F, Fakacs C, Le Mouel MA, Beurton D. Reappraisal of endoscopic sphincterotomy for post-traumatic neurogenic bladder: a prospective study. J Urol. 1996;155(1):277–80.PubMedGoogle Scholar
  55. 55.
    •• Stoffel JT. Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies. Transl Androl Urol. 2016;5(1):127–35. This is a recent review of the physiology and diagnosis of DSD. This manuscript describes adjuncts to urodynamics to diagnosing DSD. PubMedPubMedCentralGoogle Scholar
  56. 56.
    • Leitner L, Walter M, Sammer U, Knupfer SC, Mehnert U, Kessler TM. Urodynamic investigation: a valid tool to define normal lower urinary tract function? PLoS One. 2016;11(10):e0163847. This paper highlights the difficulty in diagnosing DSD with urodynamics as a proportion of healthy subjects were shown to have DSD by urodynamics. PubMedPubMedCentralGoogle Scholar
  57. 57.
    Barbalias GA, Nikiforidis G, Liatsikos EN. Vesicourethral dysfunction associated with multiple sclerosis: clinical and urodynamic perspectives. J Urol. 1998;160(1):106–11.PubMedGoogle Scholar
  58. 58.
    Wanner MB, Rageth CJ, Zach GA. Pregnancy and autonomic hyperreflexia in patients with spinal cord lesions. Paraplegia. 1987;25(6):482–90.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Hanhan Li
    • 1
  • Nickolas Nahm
    • 2
  • Alex Borchert
    • 1
  • Philip Wong
    • 1
  • Humphrey Atiemo
    • 1
    Email author
  1. 1.Vattikuti Urology InstituteHenry Ford Health SystemsDetroitUSA
  2. 2.Department of Orthopedic SurgeryHenry Ford Health SystemsDetroitUSA

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