Management of Neurogenic Bladder Disorders

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Management of Neurogenic Bladder Disorders

• Andrea Staack, MD, PhD
• Pelvic Reconstructive Surgery,
• Urinary Incontinence Female Urology
• Department of Urology
• Loma Linda University, CA

2
What will you learn during the next 20 min?

• What is happening to my bladder?
• How will I get evaluated?
• How can I improve my symptoms?
• Therapy with medication
• Invasive interventions

3
What will you learn during the next 20 min?

• What is happening to my bladder?
• How will I get evaluated?
• Simple measurements for therapy
• Therapy with medication
• Forms of interventions

4
1. What is happening to my bladder?

• 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

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1. What is happening to my bladder?

• Dual control of urination
• 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
• Central nervous system
• Voluntary control to choose when to void
• ? Both can be altered by aging or neurological
  disease

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Friedreichs ataxia andneurogenic bladder
disorder
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Uncontrolled Contraction of the Bladder Muscle
Normal bladder
Patients with urge incontinence
Patients with urge or frequency
Urethral resistance
Uncontrolled bladder muscle contractions
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1. What is happening to my bladder?

• 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

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1. What is happening to my bladder?
Overactive Bladder Symptom Experiencing a
strong urge to go to the bathroom. ? Urinary
Urgency
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1. What is happening to my bladder?
Overactive Bladder Symptom Going to the
bathroom frequently. Have to go to the
bathroom, where the bladder wakes me up at
night. ? Urinary Frequency
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1. What is happening to my bladder?
Overactive Bladder Symptom Loosing
involuntary urine accompanied with the strong
desire to void. ? Urge Urinary
Incontinence
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What will you learn during the next 20 min?

• What is happening to my bladder?
• How will I get evaluated?
• Simple measurements for therapy
• Therapy with medication
• Forms of interventions

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2. How will I get evaluated?
Hello, incontinence helpline Can you hold?
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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.
198871812-817.
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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

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

• Voiding diary day and night for gt24 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.
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2. How will I get evaluated?-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.
18
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.
19
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.
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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

Clinical Practice Guidelines Urinary
Incontinence in Adults. 1996. AHCPR publication
96-0682.
21
What will you learn during the next 20 min?

• What is happening to my bladder?
• How will I get evaluated?
• How can I improve my symptoms?
• Therapy with medication
• Forms of interventions

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3. How can I improve my 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.
200048370-374.
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3. How can I improve my symptoms?-Dietary
changes-

• Certain fluids can irritate the bladder
• Carbonated drinks
• Citrus juices
• Caffeinated drinks, e.g. soda, tea, coffee
• Alcoholic beverages

1. Burgio KL et al. J Am Geriatr Soc.
200048370-374.
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3. How can I improve my symptoms?-Dietary
changes-

• Dietary adjustments
• Fruits
• Vegetables
• High fiber intake
• Bowel regulation
• Avoid constipation and straining
• Routine defecation schedule

1. Burgio KL et al. J Am Geriatr Soc.
200048370-374.
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3. How can I improve my symptoms?-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

1. Burgio KL et al. J Am Geriatr Soc.
200048370-374.
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3. How can I improve my symptoms?-Exercises-
Pelvic floor exercise

• Helps strengthen the muscles of the pelvic floor
  improves bladder stability
• Helps suppress the feeling of urgency

Contraction
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3. How can I improve my symptoms?-Exercises-
Kegel exercise for men and women

• Find your pelvic floor muscles.
• Squeeze your pelvic floor muscles as hard as
  you can and hold them (squeeze 3-5 sec and
  relax for 5 sec).
• Do sets of repetitions of squeezing (start with
  5 repetitions squeeze, hold, relax).
• Increase lengths, intensity, and repetitions
  every couple of days.
• Perform Kegel exercises 3-4x during the day.

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3. How can I improve my 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

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3. How can I improve my symptoms?

• Bladder training
• Scheduled voiding at set times during the day
• Active use of muscles to prevent urine loss
• Increase voiding intervals after the initial goal
  is achieved
• Keep own input and output chart
• Reward increasing volumes of urinary output

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3. How can I improve my symptoms?

• Alternative therapies
• Hypnotherapy
• Yoga
• Acupuncture

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

• 6 steps for continence
• Drink less than 5 glasses/day (40 oz)
• Stop drinking after dinner
• Elevate legs
• Timed voiding
• Regular pelvic floor exercises
• Voiding diary

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What will you learn during the next 20 min?

• What is happening to my bladder?
• How will I get evaluated?
• How can I improve my symptoms?
• Therapy with medication
• Forms of interventions

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

• Drug Treatment for Overactive Bladder
• Targets bladder nerves to block uncontrolled
  contractions
• Anticholinergics
• ? Not very bladder specific

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4. Therapy with medication

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

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4. Therapy with medication

• Drug interactions between anticholinergics and
• Beta-blocker
• Drowsiness
• Dizziness
• Confusion
• Blurred vision
• Amantadine
• Urinary retention
• Dry skim

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What will you learn during the next 20 min?

• What is happening to my bladder?
• How will I get evaluated?
• How can I improve my symptoms?
• Therapy with medication
• Interventions

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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

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5. Interventions-Botox-

• 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

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5. Interventions-Botox-

• 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

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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. 2009182105561

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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

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5. Interventions-Sacral Neuromodulation-

• 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

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5. Interventions-Sacral Neuromodulation-

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

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5. Interventions

• Surgery
• Bladder denervation
• Bladder augmentation
• Bladder becomes enlarged with an extension made
  out of bowel
• Larger reservoir with lower bladder pressures

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Your bladder matters!
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1. What is happening to my bladder?

• Friedreichs ataxia and neurogenic bladder
  disorder
• Overactive bladder or
• Poor control of sphincter muscles or
• Urine retention

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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

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2. How will I get evaluated? -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.
50
Normal Voiding Cycle
Emptying phase
Filling storage phase
Bladder pressure
Normal desire to void
First sensation to void
Bladder filling
Bladder filling
Abrams P, Wein AJ. The Overactive Bladder A
Widespread and Treatable Condition. Stockholm,
Sweden Erik-Sparre Medical AB 1998.
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2. How will I get evaluated?
Medications That May Influence Bladder Function

• Narcotics
• Sedatives
• OTC-Sleep aids and cold remedies
• Antipsychotics
• Herbal remedies

• Anti-water meds (Diuretics)
• Antidepressants
• Blood pressure meds
• Hypnotics
• Pain meds

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Ive reached that age where Ive given up on
Mind Over Matter and am concentrating on Mind
Over Bladder.
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2. How will I get evaluated?-Quantification of
symptoms-

• Do you have to rush to the toilet to urinate?
• Does urine leak before you can get to the toilet?
• How often do you pass urine during the day?
• During the night, on average, how many times do
  you have to get up to urinate?
• 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
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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.
55
3. How can I improve my symptoms?

• Program to train yourself at home
• Regular Kegel exercise
• Set up voiding schedule aiming to expanding
  voiding intervals
• Active use of muscles to prevent urine loss
• Dietary changes