The department of Uro-Neurology was first set up in 1987 – so called because its aim was to take a neurological approach to bladder problems. Elsewhere an interest in neurological bladder problems had been lead by urologists so that most other specialist centres are called “Neuro-Urology Departments”. There are now a few other “Uro-Neurology” departments in the world and the subject of the neurological control of pelvic organ function is now recognised to be one of great clinical importance.
Originally providing a service predominantly for bladder problems of neurological patients at The National Hospital, the referral base has gradually expanded and the department now receives referrals from gynaecologists, urologists, neurologists, and andrologists UK wide.
In additional to the clinical service the department offers, research has been a major focus. Several important new therapies have become available in the last 10 years and research in the department has included the investigation of new treatments and their mechanism of action.
Prof Fowler was joined by part time consultants Uro-gynaecolgist Ms Elneil in 2006 and last year by Urologist, Mr Rizwan Hamid. The department now has 3 nurses, two of whom are clinical nurse specialist continence advisors. There are 2 clinical fellows and we have had a succession of visiting research fellows from Europe.
The effect of detrusor injection of botulinum toxin, a treatment introduced in Switzerland in 1999, is now recognised throughout the world as being a highly effective treatment for severe detrusor overactivity. At Queen Square the technique for giving this as a minimally invasive outpatient treatment was developed and this has been successfully used to treat patients since 2002. Still unlicensed this was used to treat patients first as a research project, but subsequently with permission of the Use of Medicines Committee at UCLH. Patients experience a relief from urinary urgency and urgency incontinence for between 9-12 months and repeated injections have proved particularly suitable for patients with Multiple Sclerosis. So far the main use of this treatment has been for patients with neurogenic detrusor overactivity of spinal rather than cerebral origin and the majority of such patients usually have a co-existent impairment of voiding. Following detrusor injections of botulinum toxin, the majority of patients have to do clean intermittent self-catherisation but despite this, an improvement in the QoL can be documented following sequential injections (see Figure 1). In the last 10 years the department has published a number of papers on the beneficial effect of detrusor injections of botulinum toxin (see a selected publication list for the last 3 years below)
In 2006 a publication from Uro-Neurology speculated on the complex mechanism of action of this treatment. Figure 2 is a summary cartoon illustrating the various concepts described in the paper. (This paper is currently the most highly cited publication in European Urology on a topic which is not related to urological cancer). Its mechanism of action is still not fully understood and we are embarking on further study of this, taking bladder biopsies from patients before and after treatment. This work is part of a European collaboration funded by an FP7 grant Incomb.
Non-surgical urinary retention is a problem for which many patients are referred, and although approximately 25% of the women are identified as having the syndrome described by Prof Fowler in 1989, research continues to try and identify significant other factors in remaining these patients. Recent data suggests that opiates may be a factor in some and may compound the problem in Fowler’s syndrome so that patients with that disorder who take opiates are particularly likely to develop urinary retention.
Sacral neuromodulation continues to be an effective treatment in restoring voiding in women with Fowler’s syndrome and the department has played an important part in establishing the mechanism of action of that intervention. It has long been a conundrum as to how sacral neuromodulation could be effective in treating symptoms of an overactive bladder and urinary retention but our research has shown that it is probably by “reinforming” the pontine micturition centre that the ability to void is restored (Figure 3). The sphincter abnormality appears to be unaffected.
Ms Elneil, consultant uro-gynaecologist, is now expanding the indications to include patients with urgency incontinence, mixed urinary incontinence, and mixed urinary and faecal incontinence. Dr Emmanuel is looking at the effects of sacral neuromodulation in bowel disorders, both intractable constipation and incontinence. A longer term study of the bowel dysfunction experienced by patients with MS has been running for the last year. The aim is to identify the physiological phenotypes of gut dysfunction and if possible identify their differing aetiologies. The ultimate aim is to target therapy specifically, for this otherwise difficult to treat group. A similar study on spinal injury has been ongoing for longer, with publications and targets emerged, the latter the subject of further trials. Ms Elneil is also going to examine the effect of pudendal nerve stimulation for voiding disorders refractory to sacral neuromodulation.
The effect of Botulinum toxin injection into the striated urethral sphincter in women with a primary disorder of sphincter relaxation (Fowler’s syndrome) is currently being investigated, both in those with complete urinary retention and those with obstructed voiding.
Information for Patients
Prof Fowler receives referrals through Choose and Book as well as GP or consultant to consultant referrals. Ms Elneil, Dr Emmanuel and Mr Hamid also run weekly outpatients to which patients can be referred by their GPs or other hospital consultants with PCT approval.
Please also see our webpage on Fowler's Syndrome
- Prof Clare Fowler
- Ms Sohier Elneil
- Dr Anton Emmanuel
- Mr Rizwan Hamid
- Dr Jalesh Panicker
- Dr Catherine Dalton
- Mr Shahid Khan
- Dr Xavier Game
- Dr Giuseppi Preziosi
- Mrs Collette Haslam
- Ms Gwen Gonzales
- Mrs Juliana Ochalur
Staff from Uro-Neurology contribute to teaching for neurologists, urologist and gynaecologists at UCL run courses, as well as national courses organized by professional training organizations and industry sponsored events. Nurses from the department are involved in teaching on their professional training courses too.
Over the course of the last year members of the department have been busy writing chapters for a book “Pelvic Organ Dysfunction in Neurological Disease”. This has been edited by Prof Fowler, Dr Jalesh Panicker and Dr Anton Emmanuel and consists of 19 chapters, all written by healthcare professionals who have worked in Uro-Neurology in recent years. The book is to be published by Cambridge University Press and a symposium with the same title is planned for this summer. All the speakers are contributors to the book.
Quality of life scores UDI -6 (Urogenital Distress Inventory -6) and IIQ -7 (Incontinence Impact Questionnaire -7) pre and post BoNT-A.