Neurogenic Bladder Disorders

Neurogenic Bladder Disorders

Dr Malith KumarasingheMBBS (Colombo)

What will you learn during the 2 hours?

1. Physiology of bladder disfunction?

2. How to evaluate?

3. What are the ways to improve symptoms?

4. Therapy with medication

5. Invasive interventions

2

• 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

3

Normal Voiding Cycle

Filling & storage phaseEmptying

phase

Bladder filling

Normal desireto voidFirst sensation

to voidBladder filling

Bla

dder

pre

ssur

e

Abrams P, Wein AJ. The Overactive Bladder — A Widespread and Treatable Condition. Stockholm, Sweden: Erik-Sparre Medical AB; 1998.

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

neurogenic bladder disorder

6

BLADDER MUSCLE SPHINCTER MUSCLES

INCONTINENCE Over activity:Muscles squeezes without

warning

Too loose:Urethra is not supported

URINARYRETENTION

Less or none activity:Muscle is too lazy

Too tight:Urination is difficult

Uncontrolled Contraction of the Bladder Muscle

Normal bladder Patients with urge incontinence

Patients with urge or frequency

Urethral resistance Uncontrolled bladder muscle contractions

7

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

“Hello, incontinence helpline – Can you hold?”

2. How to evaluate?

2. How to evaluate?-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.

13

2. How will I get evaluated?-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

14

2. How to evaluate? -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.

2. How to evaluate?-History-

• Alterations in bowel habits• Changes in sexual function• OB/GYN history• Medications( details in next slide)• Neurologic history

– Back pain, back surgery– Stroke– Numbness, weakness, balance problems

2. How will I get evaluated?

• Anti-water meds (Diuretics)

• Antidepressants

• Blood pressure meds

• Hypnotics

• Pain meds

• Narcotics

• Sedatives

• OTC-Sleep aids and cold remedies

• Antipsychotics

• Herbal remedies

17

Medications That May Influence Bladder Function:

2. How to evaluate?-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 to evaluate?-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 to evaluate?-Physical examination-

• General examination• Focused neurological examination• Genitalia and pelvic floor examination• Rectal examination

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

20

2. How to evaluate?

-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. 21

2. How to evaluate?-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. 22

2. How to evaluate?

-Invasive Tests-

• Bladder scanning with a camera (Cystoscopy)– To rule out any growth, inflammation, or stones inside the

bladder• Imaging Studies

UltrasoundX-ray studies with contrast fluid duringMRI

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

23

1. How to improve symptoms?

-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;48:370-374.25

-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


-Exercises-

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

2. Helps suppress the feeling of urgency

Contraction

Bladder Relaxation

29

Pelvic floor exercise:

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.30

Kegel exercise for men and women:

3. How to improve symptoms?

• Biofeedback therapy:–Monitors correct muscular contraction to

develop conscious control of pelvic musculature

–Voluntary contraction of the pelvic floor muscles controls urge to urinate

31

Bladder training:

1. Scheduled voiding at set times during the day2. Active use of muscles to prevent urine loss3. Increase voiding intervals after the initial goal is

achieved4. Keep own input and output chart5. Reward increasing volumes of urinary output

32

Alternative therapies:

–Hypnotherapy–Yoga–Acupuncture

33

4. How to improve symptoms?-Summary-

6 steps for continence:

1. Drink less than 5 glasses/day (40 oz)2. Stop drinking after dinner3. Elevate legs4. Timed voiding5. Regular pelvic floor exercises6. Voiding diary

34

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?


5. Forms of interventions

35

“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

37


Side effects:

•Dry mouth • Tachycardia•Constipation • Fatique•Blurred vision • Dizziness•Slow thinking

38


Drug interactions between anticholinergics and:•Beta-blocker

• Drowsiness• Dizziness• Confusion• Blurred vision

•Amantadine• Urinary retention• Dry skim

39

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

41


• 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

42


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 resistance

43

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;182:1055–61

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

45


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

46


Side effects:– Skin irritation– Pain– Wire movement– Device problems– Interaction with other devices– MRI exam not possible

47

5. Interventions

Surgery:

• Bladder denervation• Bladder augmentation

– Bladder becomes enlarged with an extension made out of bowel

– Larger reservoir with lower bladder pressures

48

“I’ve reached that age where I’ve given up on

Mind Over Matter and am concentrating on

Mind Over Bladder.”

3. How to improve symptoms?Summary

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

50

Your bladder matters!

52

Thank You!

Documents

Neurogenic Bladder Disorders