Charalampos Konstantinidis: Hello. Good morning or good afternoon. Actually, it's a great honor for me to present this topic, and as you'll see in the title, autonomic dysreflexia is a serious but rather underestimated condition. We will speak a little bit about the pathophysiology of autonomic dysreflexia and very important the heterogeneous reasons that can cause autonomic dysreflexia and some words regarding the prevention of the treatments and awareness programs. So going to pathophysiology of this entity, autonomic dysreflexia is a common complication among patients with spinal cord lesions located above the T6 level. Noxious or even non-noxious stimuli below the spinal cord lesion may initiate the onset of autonomic dysreflexia. The syndrome, of course, is well known among physicians and other healthcare professionals. It is not well known unless they are working in a spinal cord unit. And going directly to this peculiar pathophysiology, as I said before, it's something that not all the doctors are aware of because it needs to have a disruption in the spinal cord at the T6 level and above. Why? Because at the T6 level until the T6 level, the sympathetic chain is responsible, the centers, the sympathetic centers are responsible for the vasoconstriction of the vessels below this level. So let's suppose that we have a stimulation at the T6 level below the lesion. And this stimulation may be an overdistended bladder or maybe an overdistended bowel, sometimes a nail toe or even something that may cause the patient pain.
Actually these patients, they cannot feel pain, but the sympathetic system can be stimulated by the stimulus, and we can have a sympathetic response as we know the sympathetic response in the cardiovascular system can make vasoconstriction. And so we have the increase of the blood pressure. Actually the blood pressure is increased in all of our body, and then we have receptors, and they can understand we have an increased blood pressure. So there is a response from the body that we have to block the sympathetic system in order not to continue to make hypertension or upregulate the blood pressure. But actually, if the sympathetic chain is blocked due to trauma, this suppression of the sympathetic system cannot go down. So we have a continuous increase of the blood pressure, and the body cannot do anything. Of course, we have sympathetic nuclei in the cranial nerves, and maybe in the upper part of the body we can have dilatation of the vessels. So we have the half body to be red and the other half to be rather a little bit blue. And from this excessive increase of the blood pressure, we can have headache, and sometimes the pressure is so big that we have strokes or maybe cardiac infarction. As the body cannot control this situation, they cannot suppress the sympathetic system, so it starts to initiate the parasympathetic response. And actually the parasympathetic system has no access to the vessels, has access to the cardiac muscle. So we have cardiac rhythm response. So we have the paradox phenomenon of hypertension and low heart rate.
This condition is extremely dangerous if it continues, continues and goes on. Hopefully, if we take over, take out the stimulation that causes this phenomenon, things are getting back to normal. So the problem is that these individuals with spinal conditions are not institutionalized or hospitalized. They stay at their home, and they may contact any healthcare unit for any medical reason. So physicians, nurses and other therapists who deal with incontinence are likely to be asked to manage these patients with paraplegia or tetraplegia. Under the circumstances, we suppose that the deep knowledge of autonomic dysreflexia is essential for early detection, adequate treatment, and sometimes even for the life support of these patients. Even simple urologic procedures such as urodynamics, cystoscopy or sperm retrieval by vibration may lead to uncontrolled autonomic dysreflexia episodes. The awareness of the syndrome is crucial for the prevention, early detection and proper management of the syndrome. These are some urological procedures, urodynamics, cystoscopy, transurethral procedures, even sperm retrieval, even a wrong position of a catheter if we have inflated the balloon in the prostatic urethra, extracorporeal shockwave lithotripsy and other procedures, not urological, but even vigorous digital rectal evacuation or transanal irrigation and colonoscopy, these are common heterogeneous reasons that may develop autonomic dysreflexia. So the prevention, the establishment of adequate awareness among the healthcare providers and individuals with spinal cord lesion is our main goal, which may occur by a deep understanding of the pathophysiology of the entity.
The proper prevention and management of the syndrome are essential even for our patient's life. And some recommendations for the daily practice for urologists, of course we have to know the entity. We need that. Our patients should be well informed about the autonomic dysreflexia, its symptoms and trigger mechanisms. We need minimum stimulation during the diagnostic or treating procedures. We have to use flexible cystoscope to use the minimal caliber of the instrument that we can have available to avoid overdistension of the bladder in case of urodynamics, to fill the bladder on a slow rate with saline at body temperature. For the rectal catheter, to install the catheter with caution. Do not disturb the external anal sphincter with the balloon. It is advisable to monitor the blood pressure, and I finish with a very important to listen to our patients because usually they're well-informed, and they know sometimes better than their physicians. So finishing this very short presentation, we will have the time to discuss with Professor Wein the establishment of adequate awareness regarding autonomic dysreflexia among the healthcare providers and the individuals with spinal cord lesion is fundamental for the healthcare of this population and the understanding that the proper prevention and management of the syndrome are essential even for our patient's life.
Alan Wein: That was a terrific discussion. So what do the patients complain of? In other words, what are the symptoms that they usually feel when they're beginning to develop an episode of this autonomic dysreflexia?
Charalampos Konstantinidis: Usually they start to have a headache or they feel that something is knocking in their head, but at the same time they can be getting sweat usually from the upper part of the body. Due to vasoconstriction, maybe they have nausea, and sometimes they feel that they have a very big heart rate. So I think that the first that they feel is the headache, and at that time you have to measure the blood pressure.
Alan Wein: So they feel the headache because of the hypertension, and they sweat just in the upper part of their body?
Charalampos Konstantinidis: Mm-hmm. And it is important to have in our mind that usually these patients, paraplegic and especially tetraplegics, they are living with very low blood pressure. Usually their baseline blood pressure is 90, maybe 80 millimeters of mercury. So if they develop 150 or 160, it's a very huge elevation.
Alan Wein: So what sort of treatment do you institute acutely? In other words, what should we have in our office readily available? Let's say if we're doing cystoscopy on these people and they say, "I'm getting a headache, and I just don't feel right," is there anything that you can do acutely to abort this episode?
Charalampos Konstantinidis: Mm-hmm. I think that the most important is to be aware of the condition, so at the beginning to inform the patient that he has to inform us if something starts to happen. And I think that the most essential first thing is to take out the instrument and to evacuate the bladder. Usually this is enough because if you take out the stimulation, it is getting normal very quickly. In case that it's very serious or in case that there is something that we cannot do immediately, not in the office, but sometimes in the emergency rooms, maybe we have a bladder overdistension and the catheter cannot go in or whatever at the time we have to have some drugs that act very quickly depending on the country that you are, what drugs are available for the lowering of the blood pressure immediately. But the problem is that if we go with very short-acting potent drugs at the same time we take out the stimulation, maybe the blood pressure goes very, very low. So if we can get out everything that may initiate the syndrome, if we take this factor, usually the condition will get back to normal.
Alan Wein: Is there any medication that you can give prophylactically to decrease the incidence? It used to be popular I guess years ago I think Mike Chancellor published an article about giving an alpha blocker prophylactically to these people to try and lessen the impact of this. Does that work or doesn't it work?
Charalampos Konstantinidis: Sometimes we can give them in the long term, not for the iatrogenic procedures, but for the long term, yes, we can give them an alpha blocker supposing that when they have an overdistension of the bladder, supposing that the leak point pressure will be lower so they will lose some urine before getting autonomic dysreflexia. And sometimes there's a theory that also alpha blocker can also work in the central level. We do it, but I don't believe that we can avoid. If the stimulation is enough, we cannot do anything.
Alan Wein: If removing the stimulus, stopping the cystoscopy, stopping the urodynamic study, taking everything out, taking all the catheters, et cetera, if that doesn't work, then what medication can you use acutely to drop the blood pressure? Watching the blood pressure so to make sure it doesn't go too too low.
Charalampos Konstantinidis: We can use nifedipine if it is available or maybe it depends on what drugs in this country there are. Usually we use nifedipine but not in a very high dose because we're afraid of going very down the pressure. And usually if we stop very early the procedure at the beginning of the syndrome, we'll have a better outcome.
Alan Wein: Does anyone use nitro paste? It's been written up a few times that if you apply nitro paste that that will drop things as well.
Charalampos Konstantinidis: Yes, I think it works as well.
Alan Wein: Yeah. Well, thank you so much. I think this is a condition that you're correct, a lot of urologists do not know about this, and they regard neurogenic patients as well. I can do this, I can do that. And actually in many of these patients, you really have to take care and be knowledgeable about this and know what to do if it occurs and advise the patient accordingly. But we really appreciate your knowledge about this. I think this is something that all urologists should know about, and honestly I think that they don't know as much as they should about it. So thank you so much. I hope I see you at one or another of the meetings. Take care.
Charalampos Konstantinidis: For sure. Thank you. Thank you so much. Thank you. Bye.