Management of Neurogenic Bladder Disorders Andrea Staack, MD, PhD Pelvic Reconstructive Surgery, Urinary Incontinence & Female Urology Department of Urology.

Management of Neurogenic Bladder Disorders

Andrea Staack, MD, PhDAndrea Staack, MD, PhD

Pelvic Reconstructive Surgery,Pelvic Reconstructive Surgery,Urinary Incontinence & Female UrologyUrinary Incontinence & Female Urology

Department of UrologyDepartment of Urology

Loma Linda University, CALoma Linda University, CA

What will you learn during the next 20 min?

1.1. What is happening to my bladder?What is happening to my bladder?

2.2. How will I get evaluated?How will I get evaluated?

3.3. How can I improve my symptoms?How can I improve my symptoms?

4.4. Therapy with medicationTherapy with medication

5.5. Invasive interventionsInvasive interventions

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3.3. Simple measurements for therapySimple measurements for therapy


5.5. Forms of interventionsForms of interventions

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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Dual control of urination:Dual control of urination:

1.1. Autonomic nervous system controlAutonomic nervous system control– Nerve coming from the spinal cord and go directly to the bladderNerve coming from the spinal cord and go directly to the bladder

– When bladder gets fuller, signals are sent to the brain When bladder gets fuller, signals are sent to the brain

2.2. Central nervous systemCentral nervous system– Voluntary control to choose when to voidVoluntary control to choose when to void

Both can be altered by aging or neurological diseaseBoth can be altered by aging or neurological disease

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Friedreich’s ataxia andneurogenic bladder disorder

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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

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Friedreich’s ataxia and neurogenic bladder disorder:Friedreich’s 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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Overactive Bladder Symptom:

“Experiencing a strong urge to go to the bathroom.”

Urinary Urgency


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“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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“Loosing involuntary urine accompanied with the strong desire to void.”

Urge Urinary Incontinence




3.3. Simple measurements for therapySimple measurements for therapy



“Hello, incontinence helpline – Can you hold?”

2. How will I get evaluated?

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.

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• 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

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

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-Invasive Tests-


-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


-Invasive Tests-


-Invasive Tests-

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

bladder

• Imaging StudiesUltrasound

X-ray studies with contrast fluid during

MRI

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

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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. 2000;48:370-374.22


Certain fluids can irritate the bladder:

– Carbonated drinks

– Citrus juices

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

– Alcoholic beverages



• Dietary adjustments– Fruits– Vegetables– High fiber intake

• Bowel regulation

– Avoid constipation and straining– Routine defecation schedule


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


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

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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:

3. How can I improve my symptoms?

• Biofeedback therapy:Biofeedback therapy:

–Monitors correct muscular contraction to Monitors correct muscular contraction to develop conscious control of pelvic develop conscious control of pelvic musculaturemusculature

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

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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

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Alternative therapies:Alternative therapies:

–HypnotherapyHypnotherapy–YogaYoga–AcupunctureAcupuncture

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

6 steps for continence: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

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“Each capsule contains your medication plus a treatment for

each of its side effects.”

4. Therapy with medication

Drug Treatment for Overactive Bladder: Drug Treatment for Overactive Bladder:

• Targets bladder nerves to block uncontrolled Targets bladder nerves to block uncontrolled contractionscontractions

– Anticholinergics

Not very bladder specific

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Side effects:Side effects:

•Dry mouth • Tachycardia

•Constipation • Fatique

•Blurred vision • Dizziness

•Slow thinking

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Drug interactions between anticholinergics and:Drug interactions between anticholinergics and:•Beta-blocker

• Drowsiness

• Dizziness

• Confusion

• Blurred vision

•Amantadine• Urinary retention

• Dry skim

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5.5. InterventionsInterventions

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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• 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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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. 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

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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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Side effects:

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

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5. Interventions

Surgery: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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Friedreich’s ataxia and neurogenic bladder disorder:Friedreich’s ataxia and neurogenic bladder disorder:

1. Overactive bladder or

2. Poor control of sphincter muscles or

3. Urine retention

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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.

Normal Voiding Cycle

Filling & storage phaseEmptying

phase

Bladder filling

Normal desireto voidFirst sensation

to voidBladder filling

Bla

dd

er p

ress

ure

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 remedies51

Medications That May Influence Bladder Function:

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

Mind Over Matter and am concentrating on

Mind Over Bladder.”



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



• 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

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Management of Neurogenic Bladder Disorders Andrea Staack, MD, PhD Pelvic Reconstructive Surgery, Urinary Incontinence & Female Urology Department of Urology.

Documents

bladder disease

bladder overactivity

overactive bladder symptom

urinary incontinence

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urinary urgency slide

urinary frequency slide