ORIGINAL ARTICLE Urologic Dysfunction and Neurologic Outcome in Coma Survivors After Severe Traumatic Brain Injury in the Postacute and Chronic Phase Antonella Giannantoni, MD, PhD, Daniela Silvestro, PsyD, Salvatore Siracusano, MD, Eva Azicnuda, PsyD, Mariagrazia D’Ippolito, PsyD, Jessica Rigon, PsyD, Umberto Sabatini, MD, Vittorio Bini, PhD, Rita Formisano, MD, PhD ABSTRACT. Giannantoni A, Silvestro D, Siracusano S, Azicnuda E, D’Ippolito M, Rigon J, Sabatini U, Bini V, Formi- sano R. Urologic dysfunction and neurologic outcome in coma survivors after severe traumatic brain injury in the postacute and chronic phase. Arch Phys Med Rehabil 2011;92:1134-8. Objectives: To investigate voiding dysfunction and upper urinary tract status in survivors of coma resulting from trau- matic brain injury (TBI), and to compare clinical and urody- namic results with neurologic and psychological features as well as functional outcomes. Design: Observational study focused on urologic dysfunc- tion and neurologic outcome in coma survivors after traumatic brain injury in the postacute and chronic phase. Setting: A postcoma unit in a rehabilitation hospital. Participants: Consecutive patients (N=57) who recovered from coma of traumatic etiology and who were admitted during a 1-year period to a postcoma unit of a rehabilitation hospital. Interventions: Patients underwent clinical urologic assess- ment, urodynamics with the assessment of the Schafer nomo- gram and the projected isovolumetric detrusor pressure to evaluate detrusor contractility, ultrasound assessment of the lower and upper urinary tract and voiding cystourethrography, routinely performed, according to the International Continence Society Standards. Neurologic variables assessed were brain injury and disability severity, and neuropsychological status. Neuroimaging identified the site of cerebral lesions. Main Outcome Measures: Urinary symptoms, disability by means of the Glasgow Outcome Scale (GOS), and neuropsy- chological status by means of the Neurobehavioral Rating Scale (NBRS), and the relationships among them. Results: Of the 57 patients studied, 30 had overactive bladder (urge incontinence) symptoms, 28 had detrusor overactivity, and 18 had detrusor underactivity with associ- ated pseudodyssynergia in 15 of these patients. Eleven pa- tients had hypertrophic bladder; 3, bilateral pyelectasia; and 2, vesicoureteral reflux. Disability measured by GOS was severe in 8 patients and moderate in 27, while recovery was good in 22 patients. The mean NBRS total score indicated a mild cognitive impairment. Neuroimaging showed diffuse brain in- jury in all patients. Statistically significant relationships were found between urge incontinence, detrusor overactivity, and poor neurologic functional outcome, between detrusor overac- tivity and right hemisphere damage (P=.0001), and between impaired detrusor contractility and left hemisphere injuries (P=.0001). Conclusions: Most patients who recovered from coma re- sulting from TBI have symptoms of overactive bladder syn- drome and voiding difficulties. These urinary problems corre- late with cerebral involvement and neurologic functional outcome. Key Words: Brain injuries; Coma; Rehabilitation; Urinary bladder disorder; neurogenic. © 2011 by the American Congress of Rehabilitation Medicine S EVERE TRAUMATIC BRAIN injury (TBI) and coma cause numerous medical problems, among them urinary dysfunction. 1 The most frequent urinary disturbance is overac- tive bladder (OAB) (urge incontinence). The incidence ranges from 50% to 62% in the various series, 2-5 whereas urinary retention arises in only about 8% of the patients. 2 The possible causes of bladder dysfunction and voiding disturbances related to TBI and coma include midbrain dysfunction secondary to compression, ischemia or hemorrhage, and the primary trau- matic lesions. 6 Another problem is delayed recovery of vesi- cosphincter function owing to cognitive impairment. Particu- larly, as in poststroke patients, urge urinary incontinence or voiding difficulties may result from the patient’s inability to communicate the need to void, or can be related to an altered mental status and cognitive deficits, such as impaired orienta- tion in time and reduced capacity to direct attention. 7 No studies have sought correlations between urologic disturbances and neurologic features in patients who recover from coma From the Department of Urology and Andrology, University of Perugia, Ospedale Santa Maria della Misericordia, Perugia (Giannantoni, Bini); Post-Coma Unit (Sil- vestro, Azicnuda, D’Ippolito, Formisano) and Radiology Department (Sabatini), Santa Lucia Foundation, Rome; Department of Urology, University of Trieste, Os- pedale di Gattinara, Trieste (Siracusano); and San Camillo Hospital, Lido-Venice (Rigon), Italy. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Reprint requests to Antonella Giannantoni, MD, PhD, Associate Professor of Urology, Dept of Urology and Andrology, Ospedale S. Maria della Misericordia, 06100 Perugia, Italy, e-mail: agianton@libero.it. 0003-9993/11/9207-00405$36.00/0 doi:10.1016/j.apmr.2011.02.013 List of Abbreviations CT computed tomography DAI diffuse axonal injuries GCS Glasgow Coma Scale GOS Glasgow Outcome Scale MRI magnetic resonance imaging NBRS Neurobehavioral Rating Scale OAB overactive bladder PdetQmax detrusor pressure at maximum flow rate PIP1 projected isovolumetric detrusor pressure Qmax maximum flow rate TBI traumatic brain injury UDC uninhibited detrusor contractions 1134 Arch Phys Med Rehabil Vol 92, July 2011