You are on page 1of 55
Management of Neurogenic Bladder Disorders Andrea Staack, MD, PhD Pelvic Reconstructive Surgery, Urinary Incontinence & Female Urology Department of Urology Loma Linda University, CA 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? 4. Therapy with medication 5. Invasive interventions 2 What will you learn during the next 20 min? 1. What is happening to my bladder? 2. 3. 4. 5. How will I get evaluated? Simple measurements for therapy Therapy with medication Forms 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 4 1. What is happening to my bladder? 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 Friedreich’s ataxia and neurogenic bladder disorder BLADDER MUSCLE SPHINCTER MUSCLES INCONTINENCE Over activity: Muscles squeezes without warning Too loose: Urethra is not supported URINARY RETENTION Less or none activity: Muscle is too lazy Too tight: Urination is difficult 6 Uncontrolled Contraction of the Bladder Muscle Normal bladder Urethral resistance Patients with urge or frequency Patients with urge incontinence Uncontrolled bladder muscle contractions 7 1. What is happening to my bladder? 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 8 1. What is happening to my bladder? Overactive Bladder Symptom: “Experiencing a strong urge to go to the bathroom.”  Urinary Urgency 9 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 10 1. What is happening to my bladder? Overactive Bladder Symptom: “Loosing involuntary urine accompanied with the strong desire to void.”  Urge Urinary Incontinence 11 What will you learn during the next 20 min? 1. What is happening to my bladder? 2. How will I get evaluated? 3. Simple measurements for therapy 4. Therapy with medication 5. Forms of interventions 2. How will I get evaluated? “Hello, incontinence helpline – Can you hold?” 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. 14 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 2. How will I get evaluated? -Quantification of symptomsVoiding 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. 17 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. 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 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. 20 What will you learn during the next 20 min? 1. 2. What is happening to my bladder? How will I get evaluated? 3. How can I improve my symptoms? 4. Therapy with medication 5. Forms of interventions 3. How can I improve my symptoms? -Dietary changesAdequate 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 3. How can I improve my symptoms? -Dietary changesCertain 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. 2000;48:370-374. 23 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. 2000;48:370-374. 24 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. 2000;48:370-374. 25 3. How can I improve my symptoms? -Exercises- Pelvic floor exercise: 1. Helps strengthen the muscles of the pelvic floor – improves bladder stability Bladder Relaxation 2. Helps suppress the feeling of urgency Contraction 26 3. How can I improve my symptoms? -ExercisesKegel exercise for men and women: 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 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 28 3. How can I improve my symptoms? 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 29 3. How can I improve my symptoms? Alternative therapies: –Hypnotherapy –Yoga –Acupuncture 30 4. How can I improve my symptoms? -Summary6 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 31 What will you learn during the next 20 min? 1. 2. 3. What is happening to my bladder? How will I get evaluated? How can I improve my symptoms? 4. Therapy with medication 5. Forms of interventions 32 “Each capsule contains your medication plus a treatment for each of its side effects.” 4. Therapy with medication Drug Treatment for Overactive Bladder: • Targets bladder nerves to block uncontrolled contractions – Anticholinergics  Not very bladder specific 34 4. Therapy with medication Side effects: • Dry mouth • Tachycardia • Constipation • Fatique • Blurred vision • Dizziness • Slow thinking 35 4. Therapy with medication Drug interactions between anticholinergics and: • Beta-blocker • Drowsiness • Dizziness • Confusion • Blurred vision • Amantadine • Urinary retention • Dry skim 36 What will you learn during the next 20 min? 1. 2. 3. 4. What is happening to my bladder? How will I get evaluated? How can I improve my symptoms? Therapy with medication 5. 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 38 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 39 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 40 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 42 5. Interventions -Sacral NeuromodulationHow 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 43 5. Interventions -Sacral NeuromodulationSide effects: – Skin irritation – Pain – Wire movement – Device problems – Interaction with other devices – MRI exam not possible 44 5. Interventions Surgery: • Bladder denervation • Bladder augmentation – Bladder becomes enlarged with an extension made out of bowel – Larger reservoir with lower bladder pressures 45 1. What is happening to my bladder? Friedreich’s ataxia and neurogenic bladder disorder: 1. Overactive bladder or 2. Poor control of sphincter muscles or 3. Urine retention 47 2. How will I get evaluated? -HistoryRisk factors: • • • • Previous surgeries Back pain History of lumbar disc prolapse History of other urological or gynecological conditions: – Bladder prolapse – Uterine prolapse – Rectal prolapse 48 2. How will I get evaluated? -HistoryExcluding 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. Bladder pressure Normal Voiding Cycle Filling & storage phase Bladder filling First sensation to void Emptying phase Normal desire to void Bladder filling Abrams P, Wein AJ. The Overactive Bladder — A Widespread and Treatable Condition. Stockholm, Sweden: Erik-Sparre Medical AB; 1998. 2. How will I get evaluated? Medications That May Influence Bladder Function: • Anti-water meds (Diuretics) • Narcotics • Antidepressants • Sedatives • Blood pressure meds • OTC-Sleep aids and cold remedies • Hypnotics • Pain meds • Antipsychotics • Herbal remedies 51 “I’ve reached that age where I’ve given up on Mind Over Matter and am concentrating on Mind Over Bladder.” 2. How will I get evaluated? -Quantification of symptoms1. 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 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. 54 3. How can I improve my symptoms? 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 55