Management of the Neurogenic Bladder in Late Childhood to Adulthood Rosalia Misseri, MD James Whitcomb Riley Hospital for Children Indiana University School

Management of the Neurogenic Bladder in Late Childhood to Adulthood

Rosalia Misseri, MDJames Whitcomb Riley Hospital for Children

Indiana University School of Medicine Indianapolis, Indiana

Hadley Wood, MDGlickman Urological and Kidney Institute

Cleveland Clinic Cleveland, Ohio

• What is transitional urology?• When is it appropriate to consider transition?• How to transition urological care• Neurogenic bladder

– protecting kidney function

• Neurogenic bladder– managing bladder function

Overview

• Children with spina bifida grow up to become adults

• Preparation for adulthood is essential

• Encourage them to look after themselves and take part in normal family life…from the beginning

Growing Up

• How do things change?

–Urologically

–Sexually

Growing Up

CHALLENGECHALLENGE

Transition of care for this growing population

Growing Up

–Renal failure remains the most common cause of death

–Pulmonary and cardiac disease are becoming more common

–Increased risk of atherosclerosis

Growing Up

Finding a urologist who understands your problems!!!

Problem…

TRANSITION

Transitional urology

• Subspecialty care with a focus on adolescents and adults with congenital anomalies or chronic urological issues

• Requires specialty expertise in:– anatomy/congenital anomalies – reconstructive urology – knowledge of long-term effects of prior

interventions/operations

Transitional Urology

• May also need support of social work or financial services to help patients navigate medical coverage issues

• Also functions as patient advocate/liaison for other subspecialists within urology and other specialties (cardiology, neurology, etc.)

Issues addressed at initial visit• Current urological problems/needs

• Current living situation, work/school, and goals for the future

• Key players (care-providers, significant others, dependents) in patient’s life

• Quality of life concerns from parents/care-givers and patient

Issues addressed at initial visit• Detailed review of prior surgeries/interventions,

complications, and signed medical release for records

• Assessment of current status of the following:– Renal function - Stone history

– Bladder management - Sexuality issues/goals

– Infection history - Fertility issues/goals

– Fecal continence history/goals

– Urinary continence history/goals

When is it appropriate to consider transition?

• Age alone is not a good criteria

• Patient, care-provider, pediatric urologist mutually agree that the urological issues are more “adult” in nature

• When the current urologist is uncomfortable

or not capable of addressing the relevant issues

When is it appropriate to consider transition?

• When a urologist with subspecialty interest/expertise in transitional urological care can be identified

• The patient has a change of life (moving, new job, marriage, etc.) where it is reasonable to change medical care venue

How to transition urological care

• Discuss with key players

(family, care-givers, urologist)

• Gather records (and keep a copy) of all prior interventions, radiological and lab tests.

• Request a referral, consult SBA or other local resources for guidance

How to transition urological care

• Talk with other care providers (cardiologist, neurologist, etc.)

• Think about and prioritize relevant urological goals/issues

• Bring someone with you who knows your history

• Request last appointment slot of the day or double-slot

NEUROGENIC BLADDER

• Urinary problem in which the bladder does not empty properly due to a neurological condition such as spina bifida

The primary goal of the urologist is alwaysalways to maintain and preserve renal function

NEUROGENIC BLADDER: Primary Goals for Management

–Filter the blood = eliminate waste–Maintain acid-base balance

• Impacts growth & stone development–Produce some hormones

• Impacts growth & puberty–Help regulate blood pressure–Regulate fluid balance by making urine

What do the kidneys do?

• Infections

• Hydronephrosis

• Stones

• Loss of function

What can go wrong with the kidneys?

• Infections– Prophylaxis

• Prevention– Treatment

• Treat when have symptoms


• Hydronephrosis–Persistent

–New

• Changes in bladder dynamics

• Poor catheterization technique

• Blockage


• Stones– Decreased mobility

– Calcium metabolism

– Electrolyte abnormalities

– Anatomical abnormalities


LOSS OF FUNCTION• Renal failure was the most common cause

of death in spina bifida patients in past

• Renal failure still occurs in spina bifida

• It can be prevented!


x• Drink water• Prevent infection• Cath or void as directed

(TAKING CARE OF YOUR BLADDER TAKES CARE OF YOUR KIDNEYS!!)

• Take your medicine• See your doctor

– Check renal function, check bladder function

• Treat infections

Goals for the adolescent/adult patient with neurogenic bladder

• Prevent problems before they arise

• Identify which factors can be improved and which cannot

• Identify the risks of each line of treatment

• Balancing the risks and benefits of any treatment

Stores urine

Bladder function

Stores urineBladder Outlet

OUTLET

• May worsen due to outlet resistance or a tethered cord

• Outlet resistance increases–Not always a positive

Bladder function

Bladder function: tethered cord

• 25% patients age 2-8

• Usually combination of new-onset neurological, orthopedic and urological problems – 10% present with isolated

new urologic problem

Bladder function: tethered cord

• Urologic symptoms:• new onset of upper tract dilatation

(hydronephrosis)• vesicoureteral reflux • urinary incontinence• urinary tract infection

• Treatment: cord release (surgery)

• A bladder that stores urine at pressures that are too high to keep the kidneys from deterioration

• Requires consistent management– Intermittent catheterization– Anticholinergic medications – Often both– Usually first line therapy

Bladder function: neurogenic bladder

• RISKS–End stage renal damage–Social stigma and complications of

incontinence

• GOALS–Maintain healthy kidneys–Continence

Bladder function: neurogenic bladder

Causes:

– Decreased outlet resistance (sphincter)

– Bladder irritation (stone/infection)– Increased bladder storage

pressure (neurogenic bladder)– Overflow

Bladder function: incontinence

• With aging, other risk factors can increase the risk for incontinence:

– Surgery of the prostate (♂)– Vaginal childbirth (♀)– Weight gain

Bladder function: incontinence

• Behavioral: timed voiding, catheterization, avoid bladder irritants in diet

• Pharmacologic: anticholinergics

• Surgical:– Decrease storage pressure

• Botox, bladder augmentation– Increase outlet resistance

• sling, artificial sphincter

• Combination

Treatments of incontinence

• LONG TERM RISKS–STRICTURE

0-20%–TRAUMA–EPIDIDYMITIS

• ACCESS

• SUPPLIES

Treatment of neurogenic bladder: Intermittent Catheterization

• SIDE EFFECTS–Dry mouth–Constipation –Headache

• COST–Only oxybutinin is generic

Treatment of neurogenic bladder: Anticholinergics

Anticholinergic Medications: Treatment Considerations

• COST!!• Frequency of dosing• Characteristics to limit sleepiness• Limitation of other side effects (constipation)• Antispasmotic effect (intravesical oxybutinin)• Drug interactions• Delivery mechanism: oral versus

topical/transdermal/intravesical

Treatment of neurogenic bladder: Surgery

• Botox injection– Endoscopic procedure/outpatient– Onset within 2 weeks after treatment– Effect lasts ~ 6 months– Side effects rare and minor (<10%)– Efficacy:

• Reduction from baseline incontinence: 40%-80%• 65%-87% of patients became completely continent

(between caths) after Botox

– Main issue is cost/insurance coverage…

• Make the bladder larger/lower pressure–Bladder augmentation

• Make the outlet tighter–Sling, artificial sphincter


• Risks with increasing age

• Risks with increasing obesity–Infection–Cardiovascular status–Pulmonary status–Deep venous thrombosis


• Significant periods of immobility• Difficulty positioning• Difficulty accessing abdomen• Potential for fracture• Increased incidence of Latex allergies• Decline in respiratory reserve• Worsening scoliosis


• How do we decide what to do?• Urodynamics

– Gives us an idea of bladder storage pressure • > 40 mmHg is dangerous

– Gives us an idea of bladder capacity• Low capacity means frequent voiding/ISC

– Gives us an idea of outlet resistance• Tells us whether sling/sphincter can reduce

leakage




Catheterizable channel

Appendicovesicostomy

Monti-Yang

Mitrofanoff

Augmentation: Long-term concerns

• Catheterization

• Stricture

• Continence

• Tumors


LONG-TERM CONCERNS

–Stricture

–Continence

–Positioning

Treatment of neurogenic bladder: Catheterization

LONG-TERM CONCERNS

–Calculi

–Vitamin B12 deficiency

–Rupture

–Malignancy

Treatment of neurogenic bladder: Bladder augmentation

• Chronic urinary tract infections• Smoking• Inflammation

–Stones

• Indwelling catheter• Augmentation cystoplasty

–Estimated risk 1.2% to 3.8%

Treatment of neurogenic bladder: Tumors

–Seek medical assistance • Hematuria• Recurrent UTIs• Difficulties catheterizing

–Surveillance cystoscopy–Cytology

–Biopsy

–LIFELONG UROLOGIC FOLLOW-UPLIFELONG UROLOGIC FOLLOW-UP

Treatment of neurogenic bladder: Catheterizations, Bladder Augmentation & Tumors

Treatment of neurogenic bladder: outlet procedures

• May change storage pressures and jeopardize kidney function

– Requires postoperative urodynamics/monitoring

• Sphincter is not a good choice if the patient requires catheterization (prior augmentation)

• Device failure

– Sphincter- 15-30% (10 years)

– Sling- depends

• Device infection

– Sphincter- 1%

Treatment of neurogenic bladder: outlet procedures

Summary

• Bladder function changes • Goals/priorities of the patient change • Risks of interventions change• Critical to have a urologist who:

– Understands the issues – Can counsel you on realistic expectations– Has surgical and medical expertise in this field– AND IS WITH YOU FOR THE LONG HAUL!

Documents

Management of the Neurogenic Bladder in Late Childhood to Adulthood Rosalia Misseri, MD James Whitcomb Riley Hospital for Children Indiana University School