Management of Neurogenic Bladder

Management of Neurogenic Bladder Disorders

Andrea Staack, MD, PhD

Pelvic Reconstructive Surgery,

Urinary Incontinence & Female Urology

Department of Urology

Loma Linda University, CA

What will you learn during the next 20 min?

1. What is happening to my bladder?

2. How will I get evaluated?

3. How can I improve my symptoms?

4. Therapy with medication

5. Invasive interventions

2




3. Simple measurements for therapy


5. Forms of interventions


You are not alone!

40-50% in the elderly population will suffer from bladder disease in the U.S.

Risk increases with age

Can happen out of the blue or

Can have neurological causes

4


Dual control of urination:

1. Autonomic nervous system control

Nerve coming from the spinal cord and go directly to the bladder

When bladder gets fuller, signals are sent to the brain

2. Central nervous system

Voluntary control to choose when to void

Both can be altered by aging or neurological disease

5

Friedreichs ataxia andneurogenic bladder disorder

6

BLADDER MUSCLE SPHINCTER MUSCLES

INCONTINENCE Over activity:

Muscles squeezes without

warning

Too loose:

Urethra is not supported

URINARY

RETENTION

Less or none activity:

Muscle is too lazy

Too tight:

Urination is difficult

Uncontrolled Contraction of the

Bladder MuscleNormal bladder Patients with urge

incontinence

Patients with urge

or frequency

Urethral resistance Uncontrolled bladder

muscle contractions

7


Friedreichs ataxia and neurogenic bladder disorder:

More patients will most likely develop incontinence from bladder overactivity than from difficulties to empty bladder

Degenerative disease of nerve tissue in the spinal cord and peripheral nerves

Exact mechanism of bladder disorders remains unclear

8


9

Overactive Bladder Symptom:

Experiencing a strong urge to go to the bathroom.

Urinary Urgency


10


Going to the bathroom frequently.

Have to go to the bathroom, where the bladder wakes me up at night.

Urinary Frequency


11


Loosing involuntary urine accompanied with the strong desire to void.

Urge Urinary

Incontinence




3. Simple measurements for therapy



Hello, incontinence helpline Can you hold?


2. How will I get evaluated?-History-

Fluid intake pattern

Number of continent and incontinence episodes

Night time urgency

Voiding Pattern

Quality of stream

Incomplete voiding

Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

Wyman JF, et al. Obstet Gynecol. 1988;71:812-817.

14

2. How will I get evaluated?-History-

Alterations in bowel habits

Changes in sexual function

OB/GYN history

Medications

Neurologic history

Back pain, back surgery

Stroke

Numbness, weakness, balance problems

2. How will I get evaluated?-Quantification of symptoms-

Voiding diary day and night for >24 hours:

Document of fluid intake

Quantification of urine output with voiding hat

Uncontrolled loss of urine at day and night

Degree of urge to go to the bathroom

Use and number of pads

Raz, S and Rodriguez, LV: Female Urology. 3rd

edition. Saunders Elsevier, 2008.

2. How will I get evaluated?-Physical examination-

General examination

Focused neurological examination

Genitalia and pelvic floor examination

Rectal examination


17

2. How will I get evaluated?-Invasive Tests-

Urodynamic studies assess:

Uncontrolled bladder contractions

Urethral competence during filling

Bladder function during voiding

Left-over urine after urination

Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682. 18

2. How will I get evaluated?-Laboratory tests-

Urine tests

To rule out blood in the urine, kidney problems, urinary tract infections

Blood work as appropriate Blood sugar

PSA (prostate cancer)

Fantl JA et al. Agency for Healthcare Policy and Research;

1996; AHCPR Publication No. 96-0686. 19

2. How will I get evaluated?-Invasive Tests-

Bladder scanning with a camera (Cystoscopy)

To rule out any growth, inflammation, or stones inside the bladder

Imaging Studies

Ultrasound

X-ray studies with contrast fluid during

MRI


20


-Dietary changes-

Adequate fluid intake:

Not too much to avoid too frequency

Not too little to avoid bladder irritation and urinary tract infections

Reduce evening fluids to manage nighttime urination

1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.22


-Dietary changes-

Certain fluids can irritate the bladder:

Carbonated drinks

Citrus juices

Caffeinated drinks, e.g. soda, tea, coffee

Alcoholic beverages



-Dietary changes-

Dietary adjustments Fruits

Vegetables

High fiber intake

Bowel regulation

Avoid constipation and straining

Routine defecation schedule



-Lifestyle changes-

Stop smoking

To reduce chronic coughing reduces downward pressure on the pelvic floor

Weight reduction

Excessive body weight affects bladder pressure, blood flow, and nerves


3. How can I improve my symptoms?-Exercises-

1. Helps strengthen the muscles of the pelvic floor improves bladder stability

2. Helps suppress the feeling of urgency

Contraction

Bladder

Relaxation

26

Pelvic floor exercise:

3. How can I improve my symptoms?-Exercises-

1. Find your pelvic floor muscles.

2. Squeeze your pelvic floor muscles as hard as

you can and hold them (squeeze 3-5 sec

and relax for 5 sec).

3. Do sets of repetitions of squeezing (start with

5 repetitions: squeeze, hold, relax).

4. Increase lengths, intensity, and repetitions

every couple of days.

5. Perform Kegel exercises 3-4x during the day.27

Kegel exercise for men and women:


Biofeedback therapy:

Monitors correct muscular contraction to develop conscious control of pelvic

musculature

Voluntary contraction of the pelvic floor muscles controls urge to urinate

28


Bladder training:

1. Scheduled voiding at set times during the day

2. Active use of muscles to prevent urine loss

3. Increase voiding intervals after the initial goal is

achieved

4. Keep own input and output chart

5. Reward increasing volumes of urinary output

29


Alternative therapies:

Hypnotherapy

Yoga

Acupuncture

30

4. How can I improve my symptoms?-Summary-

6 steps for continence:

1. Drink less than 5 glasses/day (40 oz)

2. Stop drinking after dinner

3. Elevate legs

4. Timed voiding

5. Regular pelvic floor exercises

6. Voiding diary

31







32

Each capsule contains your medication plus a treatment for each of its side effects.


Drug Treatment for Overactive Bladder:

Targets bladder nerves to block uncontrolled contractions

Anticholinergics

Not very bladder specific

34


Side effects:

Dry mouth Tachycardia

Constipation Fatique

Blurred vision Dizziness

Slow thinking

35


Drug interactions between anticholinergics and:

Beta-blocker

Drowsiness

Dizziness

Confusion

Blurred vision

Amantadine

Urinary retention

Dry skim

36






5. Interventions

5. Interventions-Botox-

Neurotoxin, Clostridium botulinum

Injections into the bladder under direct vision

Blocks chemically nerve ends

As early as 2 days after injections it improves urgency and frequency

38


Duration between 3-6 months

Not FDA-approved for neurogenic bladder, but is widely used for failure of medical therapy

Not indicated in patients with difficulties to empty their bladders

39


Local side effects:

Excessive bladder muscle relaxation can cause urinary retention

Pain

Infections

Bleeding

General side effects:

Muscular weakness

Less effective during prolonged time

Some people build up a resistance40

5. Interventions-Electrical stimulation of the tibial nerve-

Objective alternative to medical therapy

Least invasive form of neuromodulation

Indirect stimulation of bladder nerves using a nerve at the lower leg

Recommended treatment is 12 weekly sessions of 30 minutes each

Peters KM, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol. 2009;182:105561

5. Interventions-Sacral Neuromodulation-

Pacemaker for the bladder

Treatment for urgency, frequency, urge incontinence, and urinary retention

Proven efficacy in patients for whom more conventional therapy has been unsatisfactory

Over 14 years FDA-approved

Neurologic diseases -like MS, Parkinson's disease and SCI injuries- are undergoing sacral neuromodulation with good success

42


How does it work?

Leads float next to bladder nerves

Leads are connected to a battery placed at the buttocks

Leads sent mild electrical impulses out to the sacral nerves

Can be discontinued at any time

43


Side effects:

Skin irritation Pain Wire movement Device problems Interaction with other devices MRI exam not possible

44

5. Interventions

Surgery:

Bladder denervation

Bladder augmentation

Bladder becomes enlarged with an extension made out of bowel

Larger reservoir with lower bladder pressures

45


Friedreichs ataxia and neurogenic bladder disorder:

1. Overactive bladder or

2. Poor control of sphincter muscles or

3. Urine retention

47


-History-

Risk factors:

Previous surgeries

Back pain

History of lumbar disc prolapse

History of other urological or gynecological conditions: Bladder prolapse

Uterine prolapse

Rectal prolapse

48


-History-

Excluding secondary causes:

Diabetes

Congestive heart failure

Bladder cancer

Urinary tract infections

Pregnancy

Medications

Raz, S and Rodriguez, LV: Female Urology. 3rd edition. Saunders Elsevier, 2008.

Normal Voiding Cycle

Filling & storage phaseEmptying

phase

Bladder filling

Normal desire

to voidFirst sensation

to voidBladder filling

Bla

dd

er

pre

ssu

re

Abrams P, Wein AJ. The Overactive Bladder A Widespread and Treatable Condition.

Stockholm, Sweden: Erik-Sparre Medical AB; 1998.


Anti-water meds (Diuretics)

Antidepressants

Blood pressure meds

Hypnotics

Pain meds

Narcotics

Sedatives

OTC-Sleep aids and cold remedies

Antipsychotics

Herbal remedies

51

Medications That May Influence Bladder Function:

Ive reached that age where Ive given up on Mind Over Matter and am concentrating on

Mind Over Bladder.

2. How will I get evaluated?-Quantification of symptoms-

1. Do you have to rush to the toilet to urinate?

2. Does urine leak before you can get to the toilet?

3. How often do you pass urine during the day?

4. During the night, on average, how many times do you have to get up to urinate?

5. Does urine leak after you feel a sudden need to go to the toilet?

International Consultation on Incontinence Modular

Questionnaire on Overactive Bladder in

Raz, S and Rodriguez, LV: Female Urology. 3rd ed., 2008

2. How will I get evaluated?-Physical examination-

Genitalia and pelvic floor examination:

Evaluate for uterine, bladder, rectal prolapse

Vaginal tissue thinning

Cough test

Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682. 54


Program to train yourself at home:

1. Regular Kegel exercise

2. Set up voiding schedule aiming to expanding voiding intervals

3. Active use of muscles to prevent urine loss

4. Dietary changes

55

Documents

Management of Neurogenic Bladder