MS ECHO Session 8: Neurogenic bladder and Neurogenic...

MS ECHO Session 8: Neurogenic bladder and

Neurogenic bowel

Gary Stobbe, MD Medical Director, MS Project ECHO

Clinical Assistant Professor, UW Neurology

Conflicts of Interest

• Dr. Stobbe has no conflicts of interest to disclose

Instructional Objectives • Review screening and symptoms of bladder

and bowel dysfunction • Describe medical and self-management

strategies for bladder and bowel problems • Discuss the social and emotional impact of

bladder and bowel problems

Overview • Bladder and bowel dysfunction - commonly

limit MS patients in their activities in the community – Fear of social embarrassment

• Bowel and bladder issues are very treatable with current therapies

• Not always aware their bladder and bowel issues are related to MS so screening is important

Patient Case • 65 yo male businessman with progressive MS • Wheelchair and walker • Rare UTIs in the past; urinary frequency/urgency • Rare bowel incontinence/chronic constipation • Business trip to Alaska – decreased urine

output/intractable suprapubic pain/nausea/increased LE weakness

Patient Case (cont.) • WBC – 13K; BUN – 48; Cr – 5.2 • RUA – turbid, >100 WBC • Blood Cx neg • CT abd/pelvis – hydronephrosis/hydroureter • Foley – drained 3.5 L urine

Urinary Tract Infections • Urinary tract infections (UTIs)

– common in people with a neurogenic bladder – common reason for a pseudorelapse in MS (e.g.

generalized fatigue and increased spasticity)

• May not be aware of UTI because of sensory loss

• Always first step in evaluating new bladder symptoms

Detrusor Hyperreflexia

• “failure to store” • Frequency, urgency,

incontinence, nocturia • Most common early

bladder change

Detrusor Hyperreflexia • PVR to rule out retention • Management

– Minimize bladder stimulants (caffeine) – Scheduled voiding – Reduce HS fluids (too great of a reduction may

increase infection risk and constipation) – Pelvic floor PT may be helpful – Trial of anti-cholinergic/anti-muscarinic therapy – Negative med trial - consider botox

Detrusor Hyperreflexia – Medications to reduce detrusor activity

• Oxybutynin (anti-muscarinic) • Tolterodine (selective anti-M) • Hyoscyamine (anti-cholinergic) • Propantheline (anti-cholinergic) • Trospium (Sanctura; anti-cholinergic/anti-spasmodic) • Solifenacin (Vesicare; M3 selective) • Darifenacin (Enablex; M3 selective) • Fesoterodine (Toviaz; tolterodine prodrug) • Mirabegron (Myrbetriq; beta-3 adrenergic agonist) • Imipramine (tricyclic class)

– Botulinum toxin A injections

Bladder Botulinum toxin injections • Botulinum toxin A

injections to reduce detrusor muscle overactivity

• Urologist injects numerous areas of the detrusor muscle with botox via a cystoscope

Neurogenic bladder with retention

• “failure to empty” • Urgency, hesitancy,

double voiding, feeling incomplete emptying

• Urinary retention due to – Detrusor-sphincter dyssynergia – loss of sensation – poor contractility

Case • Example: 40 yo male presents to clinic complaining that

he often has trouble voiding. He has the urge to go but when he tries, he cannot urinate. He has occasional accidents that are embarrassing for him. He is not having UTIs. No BPH.

• Management: – PVR: >200ml and/or having leaking, UTIs, or high voiding

pressures on urodynamics; a catheterization program is recommended

– PVR >200ml without leaking, UTIs, or high voiding pressure may monitor annually with renal US and creatinine

– Consider Flomax trial if BPH is considered – Urology consultation often helpful in this setting

Collaborative Decision Making for Bladder Management

• Meet patient “where” he or she is • Help patient define desired outcome • Discuss the pros and cons of medical and non-

medical interventions, including impact of some meds on cognition

Neurogenic Bowel Case: 45 year-old male with PPMS presents to

clinic due to bowel difficulties. Notes he is always constipated but when he does go it is unexpected and he has had a few accidents in public. He has since been more leery of leaving the house.

Case: 40 yo female presents to clinic due to bowel difficulties. She works full time. She is struggling with bowel urgency and incontinence. She has come close to having an accident at work

Neurogenic Bowel – Constipation Predominant

• Lifestyle – Bowel regimen – same time daily or every other (2-7 days

to see effect) – Minimize meds that worsen constipation (i.e. opioids) – Adequate hydration/fruits/vegetables/fiber – Physical exercise

• Medications – Polyethylene glycol (GlycoLax, MiraLax) – osmotic laxative – Psyllium (Metamucil) – stool bulkener – Docusate (Dulcolax, Colace) - stool softener – Bisacodyl (Dulcolax) – laxative/stimulant – Lubiprostone (Amitiza), linaclotide (Linzess) - stimulants

Neurogenic Bowel - Other Types • Fecal impaction

– Manual disimpaction

• Diarrhea – typically resulting from constipation – Disimpaction and relief of constipation

• Fecal incontinence – Bowel program – Anti-cholinergic medication

Resources • Bladder Self-Assessment Questionnaire (pdf) • Bladder Dysfunction in MS • Bowel Dysfunction in MS • Talking with Your MS Patient about

Elimination Problems

Dr. Sheri Howell’s case • 37 yo caucasian male, no prior med hx • 9/2014 – shooting pains, LLE into calf/top of foot;

dragging L foot at times • Hx LBP 1995 – “different pain” • Exam unremarkable • Medrol dosepak – no effect • Lumbar MRI – mild bulging L2-3/L3-4 • EMG/NCS unremarkable • 2/15 – notes shooting pain if turns head

Dr. Sheri Howell’s case

• C-spine MRI without contrast (2/2015) – Mild degen changes C6-7 – “increased T2 signal in the spinal cord C7”

Brain MRI – 2/2015 • Periventricular lesions highly suggestive of MS • Largest R frontal lesion with slight contrast

enhancement • Smaller corpus callosal lesions

Dr. John Schaeffer Case

• 28 yo female • Hx bipolar on lamictal • Onset L side scalp/ear pain – constant ache • Exam normal/MRI unremarkable • ENT – Ramsay Hunt? (no vesicular lesions) • Poor response to gabapentin, good response

to carbamazepine

Dr. Schaeffer Case (cont.)

• 6 mos later – neuropathic pain distal BLEs • Exam – reduced PP/temp distal to mid-calf B • EMG/NCS – mild axonal polyneuropathy • Serology – neg except B12 low (229) • Tx – B12 replacement; increase

carbamazepine (pain improved)

Dr. Schaeffer Case (cont.) • 20 mos later – R temporal/ocular pain with blurry

vision • Ophtho – dx R optic neuritis – tx with IV steroids with

prednisone taper – symptoms resolved • Neuro exam normal • Vit D – 18; anti-SSA/SSB, anti-gliadin, SPEP, lyme, TSH,

B12, ESR, ANA, anti-Hu, anti-Yo, anti-Ri all negative • Brain/cervical/thoracic WNL (8/2014 and 12/2014) • CSF – positive OCBs, elevated IgG index

12/2014 – Axial T2

12/2014 – Axial T2 FLAIR

12/2014 – Axial T2 FLAIR