Management of striated sphincter dyssynergia

Therapy of striated sphincter dyssynergia becomes mandatory as soon as the increase of outflow‐resistance causes high detrusor voiding pressure, noncompensated bladder emptying, vesico‐uretero‐renal reflux, or reflux into the male adnexa. Pharmacotherapy of striated sphincter dyssynergia so far is disappointing, the local approach for relieving sphincter spasticity by neurectomy of the pudendal nerve was abandoned at least in men because of an over 50% rate of erectile impotence. The concept of a “reversible sphincterotomy” is fascinating but not yet ready for clinical use. Nowadays, two methods are common for managing striated sphincter dyssynergia: intermittent catheterization (IC) and transurethral sphincterotomy. IC is the method of choice if a poorly sustained and lowpressure detrusor is present and if the patient stays dry in between, with or without anticholinergic medication. Otherwise, transurethral sphincterotomy by means of an anteromedian incision is the alternative. Both methods are not ideal and have definite disadvantages: IC needs instrumentation; sphincterotomy is destructive. Therefore, especially in females, a trial to empty the bladder by anal stretch is advisable and should be undertaken before other therapeutic measures are considered. A new way to achieve compensated bladder emptying is the implantation of an anterior sacral root stimulator, which also provides continence, if the relevant posterior sacral roots are out. The results so far are excellent, but further observation is necessary to prove its long‐term effects. The optimal therapy for clinically relevant striated sphincter dyssynergia can only chosen on the basis of a careful workup and with regards to the patient's personal and social situation.