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Spinal Cord Injury:
Managing the Neurogenic Bladder
Kristy M. Borawski, M.D.
Assistant Professor, Division of Urology
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Disclosures/Conflict of Interest
Pfizer: speaker
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Off Label Use
Medication
Indication
Dosage
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Overview
Spinal cord injury epidemiology
Voiding physiology
Neurogenic bladder physiology Management options
Surveillance for SCI induced neurogenic bladder
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Spinal Cord Injury (SCI)
Annual incidence 40 per million population
10,000 new injuries yearly in US
200,000 living with SCI in US
4:1 male to female ratio
Average age 30.7
Bracken, et al. Am J Epi 133: 615, 1981. Jamison, et al. Cochrane Database Sys Rev 1: 2009. Linsenmeyer, et al. JSpinal Cord Med 29: 527, 2006
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Spinal Cord Injury (SCI)
Vast majority of patients with SCI haveassociated neurogenic voiding dysfunction
~11% have associated head injury
Linsenmeyer, et al. J Spinal Cord Med 29: 527, 2006
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Life Expectancy in SCI patients
Life expectancy compared to normal population
70% of normal for complete tetraplegia
86% of normal for compete paraplegia
92% incomplete lesion with motor functioncapabilities
Yeo, et al. Spinal Cord, 36: 329, 1998
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Causes of Death in SCI patients
Renal disease historically a major cause of deathin paraplegics
1940s- 1950s: Genitourinary disorders accounted for
43% of deaths
1980-1990: 10% of deaths due to GU disorders
Clemens, et al. J Urol, 184: 213, 2010. Yeo, et al. Spinal Cord, 38: 604, 2008.
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Are we really doing better?
JD Yeo, et al: Leading cause of death amongSCI patients is pneumonia
Influenza
Septicemia**
Cancer
Heart disease
Diseases of urinary system
Suicide
CVA
Yeo, et al. Spinal Cord, 38: 604, 2000.
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Are we really doing better?
Causes of septicemia
Yeo, et al. Spinal Cord, 38: 604, 2000.
Causes Number
Urinary tract 11
Pressure areas 7
Respiratory tract 5
Strangulated bowel 3
Gangrene of the leg 2
Meningitis 2
Digestive tract 1
Gas gangrene 1
Obstruction of ileal conduit 1
Cellulitis 1
Ischemic heart disease 1
Brain stem CVA 1
Chronic lymphatic leukemia 1
Total 37
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Neural Control of the Lower
Urinary Tract
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Wein, et al. Campbell-Wash Urology, Vol 3, 2007
Function of the lowerurinary tract
Fill to normal capacity atlow pressures
Store urine until sociallyacceptable time to void
Empty to completion atacceptable pressures
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Wein, et al. Campbell-Wash Urology, Vol 3, 2007
Neural Control
Three sets of peripheral nerves innervate thelower urinary tract
Parasympathetic
Sympathetic
Somatic
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Wein, et al. Campbell-Walsh Urology, Vol 3, 2007
Neural Control: Parasympathetic
Originate from sacral cord at S2-S4
Preganglionic efferent fibers travel via pelvic nervesto provide excitatory input to the bladder
Post ganglionic nerves excite bladder smooth
muscle via:
Cholinergic (muscarinic receptors)
M2/M3 exist in bladder
M3 mediate bladder contractions Non-adrenergic, non cholinergic (ATP) acting on
P2X1 purinoreceptors
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Wein, et al. Campbell-Walsh Urology, Vol 3, 2007
Neural Control: Sympathetic
Begins in intermediolateral gray column fromT11L2
Route to bladder
Sympathetic chain ganglia inferior mesentericganglia hypogastric nerves to pelvic ganglia
Activation results in:
Bladder relaxation: via fibers
Contraction of bladder outlet & urethra: via fibers
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Wein, et al. Campbell-Walsh Urology, Vol 3, 2007
Neural Control: Somatic
S2-4 motor innervation (Onufs nucleus)
Travels to external sphincter via Pudendal nerve
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Wein, et al. Campbell-Walsh Urology, Vol 3, 2007
Micturition Centers
Cerebral Cortex
Inhibitory signal to thesacral micturition center
Pontine micturition center
Coordinating relaxation ofurinary sphincter whenbladder contracts
Sacral micturition center
Efferent parasym. signalscause bladder contraction
Afferent impulses provideinformation on bladderfullness
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Wein, et al. Campbell-Walsh Urology, Vol 3, 2007
Afferent Bladder Signals
Pelvic nerve afferents
Monitor volume of bladder & amplitude of bladdercontraction
Myelinated A and Unmyelinated C axons
C fibers are not essential for normal voiding
Wake up and respond to bladder distention & stimulate
uninhibited bladder contractions in animal models with
suprasacral spinal cord injury
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General Patterns of Neurogenic
Bladder after Neurologic Injury
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Lesions above Brainstem
Removes cerebral cortex micturition center
Detrusor overactivity
Coordinated sphincter control
Sensation may be normal or altered
Overall: urinary urgency +/- urge incontinence
Detrusor areflexia may occur initially or as permanent
dysfunction
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Suprasacral Spinal Cord Injury
Removes cerebral cortex & pontine micturition
centers
Spinal shock at first
Detrusor overactivity
No (reduced) sensation
Detrusor external (striated) sphincter dyssynergia
Present in >90% of patients with suprasacral SCI
Detrusor internal (smooth) sphincter synergia If lesion above T6, results in dyssynergic smooth
sphincter
Overall: incontinence due to detrusor overactivity
with obstruction due to DSD
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Sacral Spinal Cord Injury
Removes all micturition centers
Spinal shock at first
Detrusor areflexia
Decreased compliance may occur
Open internal (smooth) sphincter
Residual resting striated sphincter tone not undervoluntary control
Result: retention +/- incontinence
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Kaplan, et al: Urodynamic findings of 489 SCIpatients
Cervical lesion 15% detrusor acontractility
85% NDO & DSD
Thoracic
NDO with 90% showing DSD
Lumbosacral
40% detrusor acontractility
30% NDO 30% NDO and DSD
Kaplan, et al. J Urol, 1991.
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Kaplan, et al: Urodynamic findings of 489 SCI
patients Sacral level lesion
Small portion with normal urodynamics
64% with detrusor acontractility
Kaplan, et al. J Urol, 1991.
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Changes in Afferent Activity After
Spinal Cord Injury
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Changes in Afferent Activity AfterSpinal Cord Injury
Spinal Shock
Absent somatic reflex activity and flaccid muscleparalysis
Suppression of autonomic activity & somatic activity
Bladder is acontractile & areflexic
Bladder neck is usually closed (unless prior surgery)
Urinary retention is the rule Lasts 6-12 weeks
Return of reflex bladder activity occurs along withrecovery of lower extremity deep tendon reflexes
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After resolution of spinal shock, there is slow
development of autonomic micturition withneurogenic detrusor overactivity
Mediated by spinal reflex pathways
Voiding usually is inefficient due to presence of noncoordinated sphincters
Bladder contracts and external sphincter contracts rather
than relaxes detrusor sphincter dyssynergia
Yashimura, et al. Neurol Urod, 29: 63, 2010
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Afferent Changes
Recovery of bladder function after SCI isdependent on:
Plasticity of bladder afferent pathways
Unmasking of reflexes triggered by unmyelinated,capsaicin-sensitive C-fiber bladder afferent neurons
C-fiber afferents are activatedAdministering C-fiber neurotoxin capsaicin to SCI cats
blocks reflex bladder contractions
No effect in spinal cord intact cats
Yashimura, et al. Neurol Urod, 29: 63, 2010
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De Groat, et al. Exp Neurol, 2011.
Afferent Bladder Signals:
Changes After SCI Reactivation of neonatal
perineal-to-bladder andbladder-to-bladder
excitatory reflexes Activation of C mediated
afferents
Alteration in epitheliallayer
In rat model, removingmucosa eliminated NDO
Morphological &chemical change ofafferents
Remodeling of synapsesin spinal cord
Alteration inneurotransmittermechanisms in spinalcord
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Evaluating the Neurogenic
Bladder after SCI
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Guidelines
Third International Consultation onIncontinence
Committee on neurogenic bladder management
No SCI specific protocols
European Association of Urology
Overall management recommendations for
neurogenic bladder
No SCI specific protocols
Wyndaele, et al. The 3rd International Consultation of Incontinence, 2004. Stohrer, et al. European Association ofUrology Guidelines, 2007.
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European SCI Think Tank
Defines 4 stages of management
Immediate (within first few days)
Early management (0-2 weeks)
Intermediate management (2-12 weeks)
Long term management (>12 weeks)
Abrams, et al. BJU Int, 101: 989, 2008
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European SCI Think Tank
Immediate management
Resuscitation time
Usually requires indwelling catheter (urethral) for
monitoring
Early management (0-2 weeks)
Remove indwelling catheter
Institute clean intermittent catheterization (CIC)
Abrams, et al. BJU Int, 101: 989, 2008
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European SCI Think Tank
Intermediate management (2-12 weeks)
Transition from inpatient rehabilitation home
Introduce/refer to urology
Discuss urological options
Consider obtaining baseline testing
Abrams, et al. BJU Int, 101: 989, 2008
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Baseline Interventions: 3-6 months
After resolution of spinal shock
Renal function
Serum creatinine
Creatinine clearance until muscle mass stable
Renal/bladder ultrasound
Frequency/volume bladder chartVideo urodynamics
Abrams, et al. BJU Int, 101: 989, 2008
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Urodynamics in the SCI patient
Grade A evidence to support the use of videourodynamics in patients with neurogenic lower
urinary tract dysfunction
Stohrer, et al. Eur Urol, 56: 81, 2009.
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Urodynamics in the SCI patient
Fill/Storage phase
Normal capacity
Normal compliance
>12.5mL/cmH20 No detrusor overactivity
Competent outlet
Emptying phase
Sphincter relaxation
Sustained detrusorcontraction
Minimal residual urine
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Normal Urodynamics
Filling Storage Voiding
Rectal catheter
Urethral Catheter
Detrusor Pressure = Pves - Pabd
U d i fi di h l
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Urodynamics findings that place
upper tracts at risk
Poor Compliance
High storage pressure VUR Upper tract deterioration
McGuire, et al
Storage pressure >40cmH2O associated with renal dysfunction
Detrusor leak point pressure
Ideally, would keep pressure
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Urodynamics findings that place
upper tracts at risk Detrusor external sphincter dyssynergia
Results in high voiding pressures
Vesicoureteral reflux
Incomplete bladder emptying
Symptoms:
Weak stream
Intermittent stream
d i fi di h l
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Urodynamics findings that place
upper tracts at riskThree types of detrusor sphincter dyssynergia
U d i fi di h l
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Urodynamics findings that place
upper tracts at risk Neurogenic detrusor overactivity
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Options for Bladder Management
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Options for Management
Patient abilities
Tetraplegic vs. paraplegic
Concurrent head injury
Patient preference
Family support
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US Clinical Practice Guidelines
CIC is optimal option for bladder emptying
Recommend institution of CIC program prior todischarge from rehabilitation unit
Popularized by Lapides in 1972
Safe method for bladder drainage
Decreased rates of UTI, bladder stones & erosion
Numerous studies documenting patientacceptance
Kessler, et al. Neurourol & Urod, 28: 18, 2009. J Spinal Cord Med, 29: 527, 2006
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US Clinical Practice Guidelines
Cameron, et al: long term data available onbladder management for 12,984 SCI patients
Cameron, et al. J Urol 184: 213, 2010.
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US Clinical Practice Guidelines
Use of CIC drastically declined
Cameron, et al. J Urol 184: 213, 2010.
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US Clinical Practice Guidelines
CIC use not indicated / difficult in patients with:
Abnormal urethral anatomy
Bladder capacity
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US Clinical Practice Guidelines
Complications/problems associated with CIC
UTI
Bladder overdistention
Urinary incontinence
Urethral trauma with false passage
Urethral stricture
Bladder stones
Autonomic dysreflexia
Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006
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US Clinical Practice Guidelines
Crede Voiding / Valsalva Voiding
Application of suprapubic pressure or abdominalstraining to empty bladder
Only consider if patient has low outlet resistance
Current recommendation: Consider avoiding Crede andValsalva as primary methods of bladder emptying
Grade C recommendation
Avoid if known history of vesicoureteral reflux
Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006
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US Clinical Practice Guidelines
Reflex voiding into external collection device / pads
Only consider if:
Low voiding pressures on urodynamics
Low post void residualsAbsent / rare episodes of autonomic dysreflexia with bladder
filling
Rare UTIs
Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006
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US Clinical Practice Guidelines
Indwelling catheter (urethral / suprapubic) 23% of SCI patients are discharged from rehab units
with indwelling catheters
Higher complication rates compared to CIC
53.5% complication rate in indwelling group vs. 27% for CIC
Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006. Dmochowski, et al. J Urol, 163: 768, 2000.
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US Clinical Practice Guidelines
Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006, Dmochowski, et al. J Urol, 163: 768,
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US Clinical Practice Guidelines
Increased risk of upper tract deterioration withindwelling catheter
Low bladder compliance
Leads to increase risk of VUR pyelonephritis
Mean serum creatinine is higher
Proteinuria is greater in patients with indwelling
catheters
Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006
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US Clinical Practice Guidelines
Increased risk of upper tract deterioration withindwelling catheter
Addition of anticholinergic may help
Improved bladder compliance
Lowers detrusor leak point pressure
Decreased rates of hydronephrosis
No change in:
Infection rates
VUR
Serum creatinine
Renal scars
Kim, et al J Urol 159: 193, 1998. J Spinal Cord Med, 29: 527, 2006
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US Clinical Practice Guidelines
Increased risk of bladder cancer with indwellingcatheter
Reported incidence of squamous cell carcinoma (SCC) is
2.310% in patients with indwelling catheter 8% risk after 25 years of catheterization
Pathogenesis: chronic urothelial irritation and
inflammation leading to metaplasia neoplasia
Surveillance guidelines for cystoscopy differ
Annual surveillance for patients with indwelling catheters is
advised
J Spinal Cord Med, 29: 527, 2006. Corcos, et al. Neurourol & Uds 27: 475, 2008.
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Urethral vs. Suprapubic Catheter
Similar overall complication rates with notableexceptions
Urethral complications significantly higher in urethral
catheter group Erosion (especially in women), abscess, fistula, stricture
Slight decreased risk of UTI with suprapubic catheter
Benefit may be offset by increased risk of insertion
Recent studies using modernized techniques showimproved outcomes for indwelling catheters
J Spinal Cord Med, 29: 527, 2006. Corcos, et al. Neurourol & Uds 27: 475, 2008.
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When bladder drainage alone
is not enough
Si n /S mpt m f
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Signs/Symptom of
Insufficient Treatment
Worsening upper tracts
Hydronephrosis on RUS
Increased serum creatinine
Worsening urodynamics
Loss of compliance, elevated DLPP, increasedvoiding pressures, worsening NDO
Increased incontinence
Increased episodes of autonomics dysreflexia
Patient dissatisfaction
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Medications
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Medications
Goal of medical therapy
Improve bladder compliance
Increase bladder capacity
Decrease neurogenic detrusor overactivitydecrease incontinence
Acceptable side effects
Antim rini
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Antimuscarinics
First line agents for patients with neurogenicbladder
Some advocate starting immediately
5 muscarinic receptor subtypes; 2 in bladder
Normally, M3 receptors mediate bladdercontractions
Cameron, et al. J Urol, 182: 1062, 2009. Stevens, et al. Eur Urol 52: 531, 2007.
Antim c rinic
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Antimuscarinics
Dose requirements are usually higher than inpatients with idiopathic detrusor overactivity(Grade A)
Not all anticholinergics have data for neurogenic
population
Abrams, et al. BJU Int, 101: 989, 2008. Stohrer, et al. Eur Urol, 56: 81, 2009.
Anticholinergics
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Anticholinergics
Muscarinic Receptor Subtypes
Subtype Distribution Role
M1 Brain (cortex, hippocampus), Salivary
gland
Cognitive function, memory; saliva
secretion
M2 Heart, brain, smooth muscle Regulation of heart rate & HRvariability; behavioral flexibility
M3 Smooth muscle, glands, eye Smooth muscle contraction, iriscontraction, gland secretion
M4 Brain (forebrain, striatum) Dopamine dependent behaviors
M5 Brain (substantia nigra), eye Regulation of striatal dopamine release
Anticholinergics
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Anticholinergics
Antimuscarinics & M3 Receptor Selectivity
Anticholinergics
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Anticholinergics
Antimuscarinics & Side Effects
Dry mouth
Constipation
Blurred vision
Anticholinergics
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Anticholinergics
Constipation Dry Mouth
Enablex 7.5mg 14.8% 20.2%
15mg 21.3% 35.3%
Vesicare 5mg 5.4% 10.9%
10mg 13.4% 27.6%Sactura XL 60mg 8.5% 10.7%
Detrol LA 4mg 7% 35%
Toviaz 4mg 4.2% 18.8%
8mg 6% 34.6%
Anticholinergics:
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gCognitive Side Effects
Merchant, et al.
Prevalence of cognitive impairment more thandoubled with the use of drugs with anticholinergic
activity in community dwelling older persons
CNS Penetration
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CNS Penetration
Entry into the brain via BBB by passivediffusion dependent on:
Molecular size, polarity, lipophilicity
Highly lipophilic, non polar small molecules willmore readily cross the BBB by passive diffusion
Oxybutynin: 357kDareadily passes BBB
Darifenacin, solifenacin, tolterodine, fesoterodine all
>475kDa unlikely to pass via passive diffusion
Tropsium (Sancura) hydrophilic, polar compound,
428kDa low propensitiy for BBB penetration
Cognitive Impairment &
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g pReceptor Selectivity
M1 & M2 receptors are important in cognitivefunctioning and memory & behavioral flexibility& learning
More data that central blockade of M1 receptors has
a key functional role in cognitive impairment
Less M3 selectivity may be associated with increasedrisk of cognitive impairment
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Sanctura (tropsium): although relatively non-selective, low BBBpenetration should have low potential for cognitive risk as longas BBB integrity is not compromised
As of now, best evidence is with darifenacin (enablex): 3 trials
Alpha Blockers
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Alpha Blockers
Detrusor has 2 types 1 adrenergic receptor
1/3: 1-d 2/3: 1-a
Bladder neck, prostate: predominantly1-a
Sundin, et al: Increase in adrenergic receptor sites anda switch to -adrenergic contractive function from thetypical -adrenergic relaxation function during bladderfilling
Tamsulosin (flomax) RCT: no significant increase inbladder capacity
Cameron, et al. J Urol, 182: 1062, 2009.
Tricyclic antidepressants (TCAs)
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Tricyclic antidepressants (TCAs)
Imipramine has been shown to suppress bladder
overactivity by various mechanisms Muscarinic receptor antagonist
Direct smooth muscle inhibitor
Blocks reuptake of serotonin reduces bladder overactivity
Also shown to stimulate fibers at dome resulting in
improved bladder compliance
TCAs (Imipramine) have been shown to increase
compliance in the pediatric neurogenic population No RCT supporting their use
Cardiac side effects use with caution
Cameron, et al. J Urol, 182: 1062, 2009.
Combination therapy
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py McGuire, et al: retrospectively evaluated group of
patients initially on no medications or antimuscarinics
only
No initial medications
2 medications (n=22)
Mean bladder pressure at capacity decreased 52% (36
17cmH20) Mean compliance increased 5-fold (11.3 56.3 mL/cmH20)
3 medications (n=28)
Bladder pressure decreased 67% (35.9 11.9cmH20)
Compliance increased 9.7 fold (7.2 69.6mL/cmH20)
Initial antimuscarinics 3 drug therapy (n=27)
Bladder pressure decreased 60% (27.2 10.9 cmH20)
Compliance increased 3-fold (18.4 54.3 mL/cmH20)
Cameron, et al. J Urol, 182: 1062, 2009.
Combination therapy
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py Other studies support the use of combination therapy
Gossl, et al: 41 children with MMC treated with oraloxybutinin
40% increase in capacity
158% increase in compliance
Swierzewski, et al: added terazosin (alpha blocker) toexisting CIC + anticholinergic therapy
Compliance increased by 73%
Capacity increased by 157mL
Bladder pressure decreased by 36cmH20
Results reversed when medication stopped
Cameron, et al. J Urol, 182: 1062, 2009. Swierzewski, et al. J Urol, 151: 951, 1994.
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Failure Despite Maximal Medical
Therapy
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Historically, progressed to surgical managementor an indwelling catheter
Sphincterotomy
Bladder Augmentation
Ileovesicostomy
Urinary Diversion
Botox
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Botulinum Toxin A
Isolated in 1897 by van Ermengem 150-kD amino acid di-chain
Mechanism of action
Binds to pre-synaptic nerve endingsof cholinergic neurons
Enters neuron via endocytosis
Cleaves SNAP-25 protein that isneeded for synaptic vesicle fusion
Results in inhibition of acetylcholinesecretion
Karsenty, et al. Eur Urol 53: 275, 2008. Reitz, et al. Eur Urol 45: 510, 2004.
B
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Botox
Increasing evidence of increased activity
Inhibits release of acetylcholine, adenosinetriphosphate and several neurotransmitters
(substance P) Down-regulates expression of purinergic & capsaicin
receptors on afferent neurons in the bladder
Botox can treats neurogenic detrusoroveractivity via motor & sensory pathways
Karsenty, et al. Eur Urol 53: 275, 2008.
Botulinum toxin
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o u u o
Seven distinct structurally similar serotypes ofbotulinum toxin (BTX)
BTX-A & BTX-B have been used in variousneurological disorders
BTX-A (Botox, Allergan, Inc) approved for use in USby FDA for strabismus, blepharospasm, hemifacial spasm& cervical dystonia
Karsenty, et al. Eur Urol 53: 275, 2008.
Botulinum toxin: update!!
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p
August 24, 2011
BOTOX (onabotulinumtoxinA) Receives U.S.
FDA Approval For The Treatment Of Urinary
Incontinence In Adults with Neurological
Conditions Including Multiple Sclerosis AndSpinal Cord Injury
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Karsenty, et al. Eur Urol 53: 275, 2008.
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Karsenty, et al. Eur Urol 53: 275, 2008.
Significant improvement incontinence rates
Significant improvement in QOLparameters
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Karsenty, et al. Eur Urol 53: 275, 2008.
Significant improvement of maximum detrusor pressure
RCT Botox vs. Placebo for NGB
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Herschorn, et al. J Urol, 2011.
Secondary to SCI/MS
Herschorn, et al. RCT comparing 300 Units or placebo
30 injection sites
Trigone sparing
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Herschorn, et al. J Urol, 2011.Adverse Events
Ideal Dosage for Botox Still Unknown
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Cruz. Eur Urol, 2011.
Improvement with 200 & 300 units in
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Cruz. Eur Urol, 2011.
p
SCI population
Improvement with 200 & 300 units in
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Cruz. Eur Urol, 2011.
p
SCI population
Slight increase in SE for 300 Units
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Cruz. Eur Urol, 2011.
Slight increase in SE for 300 Units
Long Term Data
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Pannek, et al. BJU Int 104: 1246, 2009.
Multiple studies document long term success
despite the need for repeat injections 4-9 months
Pannek, et al: declining results with repeated
injections 1 in 4 subjects required surgical intervention
Are the Results Sustainable?
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Are the Results Sustainable?
Giannantoni, et al
Giannantoni, et al. 2009 Eur Urol; 55: 705-712
Improvement in QOL index
Repeated Injections
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Treatment resistance or lack of response
Antibody formation a concern for repeated injection No formal studies documenting the presence of antibodies in
non responders in urologic literature
In cervical dystonia: subjects with antibodies required shorter intervals
between injections and required larger doses Schulte-Baukloh, et al
Of 25 subjects who received BoNTA, 4 tested + forantibodies & 4 were borderline
Only 3/8 were considered treatment failures
Dowson, et al. 2010 Nat Rev Urol; 7: 661-667.
Side Effects
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Pannek, et al. BJU Int 104: 1246, 2009. Karsenty, et al. Eur Urol 53: 275, 2008.
Side effects are usually mild
Injection site pain
Procedure-related UTI (2-23%)
Mild hematuria (2-21%)
Elevated PVR
De novo need for CIC (6-88%) Localized muscle weakness reported
Documented reports of generalized weakness / fatiguefollowing Botox injections
Warn patients about black box warning with BoNTA
Potential to spread beyond treatment area & producedifficulty swallowing and breathing
Contraindications
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Pregnancy category C
Relative contraindication in patients with neuromusculardisease
Use caution with certain medications that can potentiate
the results of BoNTA Aminoglycosides
Clindamycin
Succinylcholine
Gomez, et al. 2010 Curr Urol Rep; 11: 353-359.
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Sacral Neuromodulation
Sacral Neuromodulation: Interstim
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Sacral Neuromodulation: Interstim
Sacral Neuromodulation: Interstim
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Complete spinal cord injury
Poor outcomes reported with use of Interstim Incomplete injuries
Limited data available that appears to support its use
Lombardi, et al. Spinal Cord, 47: 486, 2009.
Early Sacral Neuromodulation(SNM)?
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(SNM)?
Could early neuromodulation prevent theplasticity that results in a neurogenic bladder?
Sievert, et al: 10 patients received bilateral SNM
6 who refused served as controls
All were complete SCI above T12
Prior to intervention, UDS confirmed areflexia duringspinal shock period
Time to SNM implantation: 2.9 months (0.84.5months)
Sievert, et al. Ann Neurol, 67: 74, 2010
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Sievert, et al. Ann Neurol, 67: 74, 2010
SNM group
Control
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How should we monitor the SCI
patient?
How should we monitor the SCIpatient?
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patient?
US Practice Guidelines No definitive
recommendations
Upper & lower tract
evaluation annually
How should we monitor the SCI patient?
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How should we monitor the SCI patient?
Veterans Affairs Health Care policyAnnual UA, C&S
Annual BUN, serum creatinine
Annual anatomical exam (renal US / CT) Urodynamics should be performed when objective
information on voiding function is needed
Cystoscopy every 10 years in patients with indwellingcatheters or who use tobacco products
How should we monitor the SCI patient?
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How should we monitor the SCI patient?
Proposed European Guidelines
Annual urodynamics for high risk group (detrusor overactivity,low bladder compliance, reflex voiding, Crede voiding)
Biannual urodynamics for low risk group
How should we monitor the SCI patient?
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How should we monitor the SCI patient?
Prior guidelines recommended annual UDSevery 5 years & then with symptom / uppertract change
Nossier, et al: 3/80 patients did not requiretreatment modification (mean f/u 67 months)
If UDS were repeated based on symptom/upper
tract findings only, 68% of treatment failure (i.e.those needing treatment modification) would nothave been identified
Nossier, et al. Neurourol Urodyn 26(2): 228, 2007.
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Other Considerations
Bladder Cancer
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Relative risk of bladder cancer 1628 timesthat of the normal population
Recent review of 1319 spinal cord patients
32 developed cancer
46.9% SCC, 31.3% TCC, 9.4% adenocarcinoma,12.5% mixed SCC/TCC
Bladder management: 44% urethral catheter, 48%
external catheter, 8% CIC 42% found on screening cystoscopy
Kalisvaart, et al. Spinal Cord, 48: 257, 2010. Goath, et al. Arch Phys Med Rehabil, 83: 346, 2002.
Bladder Cancer
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Causes of increased bladder cancer
Chronic irritation
Recurrent UTI
Bladder stones
Indwelling catheterAlteration in bladder urothelial due to interaction of
bladder mucosa with high volume of urine
Average time from injury
bladder cancer dx 34 years
Kalisvaart, et al. Spinal Cord, 48: 257, 2010. Goath, et al. Arch Phys Med Rehabil, 83: 346, 2002.
Cystoscopy Recommendations
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With symptoms
Hematuria
Recurrent UTI
Any significant change in urinary habits
Annual
Consider in indwelling catheter group
Consider in high risk patients (recurrent UTI,
bladder stones, tobacco use, etc..)
Kalisvaart, et al. Spinal Cord, 48: 257, 2010. Goath, et al. Arch Phys Med Rehabil, 83: 346, 2002.
Conclusion
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SCI associated with significant GU dysfunction
Prompt referral to center of excellence for SCIpatients is preferred
Early & lifelong GU involvement
If you care for SCI patients, ensure that they arereceiving urologic care.