Duloxetine for treatment of male sphincteric incontinence following partial conus medullaris infarction after coronary bypass surgery

Abstract

Introduction: Vascular spinal cord injury following coronary bypass grafting surgery is very rare and this is probably one of few reports of a presumptive partial conus medullaris lesion leading to sudden onset bladder and bowel incontinence which was managed using duloxetine, a selective serotonin and norepinephrine reuptake inhibitor. Duloxetine has been used in selected patients with post-prostatectomy sphincteric incontinence but not, to our knowledge, for spinal vascular lesions.

Case presentation: A 63-year-old Indian man developed bladder and bowel incontinence immediately following coronary bypass grafting surgery. Findings were suggestive of microcirculatory partial conus medullaris infarction. Based on his urodynamics findings he was managed with duloxetine, tolterodine and clean intermittent catheterization. The clinical presentation, serial urodynamic findings and implications are discussed.

Conclusion: Spinal injury following coronary bypass grafting is rare and devastating. It is important to be able to recognize the problem even when paraplegia is not noted, counsel the patient and manage the patient with the help of urodynamics. In patients with sphincteric incontinence, duloxetine may have a role in management.

Figure 1

Initial urodynamics study. Urodynamic study prior to duloxetine (Nov 2004, 4 months after onset) done in lying down position (since the patient had a very lax anal sphincter). There was severe leak (L) noted on minimal abdominal straining. Continuous pericatheter leak was noted at 225 ml at a pressure of 19 cm H20. He had an acontractile detrusor.

Figure 2

Follow up urodynamics study. Follow up urodynamic study after commencing 40 mg twice daily Duloxetine (Aug 2005). Patient also on tolterodine sustained release 4 mg once daily. No leak was observed on cough (C) or valsalva (V) and there was no pericatheter leak on filling beyond 400 ml (not depicted; separate cycle of filling).