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Neurogenic Bladder Disorders

Neurogenic Bladder Disorders. Dr Malith Kumarasinghe MBBS (Colombo). What will you learn during the 2 hours?. Physiology of bladder disfunction ? How to evaluate? What are the ways to improve symptoms ? Therapy with medication Invasive interventions.

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Neurogenic Bladder Disorders

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  1. NeurogenicBladder Disorders Dr MalithKumarasinghe MBBS (Colombo)

  2. What will you learn during the 2 hours? • Physiology of bladder disfunction? • How to evaluate? • What are the ways to improve symptoms? • Therapy with medication • Invasive interventions

  3. 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. 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.

  5. 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

  6. neurogenicbladder disorder

  7. Uncontrolled Contraction of the Bladder Muscle Normal bladder Patients with urge or frequency Patients with urge incontinence Urethral resistance Uncontrolled bladder muscle contractions

  8. neurogenicbladder 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

  9. Overactive Bladder Symptom: • “Experiencing a strong urge to go to the bathroom.” •  Urinary Urgency

  10. Overactive Bladder Symptom: • “Going to the bathroom frequently.” • “Have to go to the bathroom, where the bladder wakes me up at night.” •  Urinary Frequency

  11. Overactive Bladder Symptom: • “Loosing involuntary urine accompanied with the strong desire to void.” •  Urge Urinary Incontinence

  12. 2. How to evaluate? “Hello, incontinence helpline – Can you hold?”

  13. 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.

  14. 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

  15. 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.

  16. 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

  17. 2. How will I get evaluated? Medications That May Influence Bladder Function: • Anti-water meds (Diuretics) • Antidepressants • Blood pressure meds • Hypnotics • Pain meds • Narcotics • Sedatives • OTC-Sleep aids and cold remedies • Antipsychotics • Herbal remedies

  18. 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.

  19. 2. How to evaluate?-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

  20. 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.

  21. 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.

  22. 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.

  23. 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 • Ultrasound • X-ray studies with contrast fluid during • MRI Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

  24. How to improve symptoms?

  25. -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.

  26. -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. 2000;48:370-374.

  27. -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.

  28. -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.

  29. Helps strengthen the muscles of the pelvic floor – improves bladder stability Helps suppress the feeling of urgency Bladder Relaxation -Exercises- Pelvic floor exercise: Contraction

  30. 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.

  31. 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

  32. 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

  33. Alternative therapies: • Hypnotherapy • Yoga • Acupuncture

  34. 4. How to improve 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

  35. 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

  36. “Each capsule contains your medication plus a treatment for each of its side effects.”

  37. 4. Therapy with medication Drug Treatment for Overactive Bladder: Targets bladder nerves to block uncontrolled contractions Anticholinergics  Not very bladder specific

  38. 4. Therapy with medication Side effects: Dry mouth • Tachycardia Constipation • Fatique Blurred vision • Dizziness Slow thinking

  39. 4. Therapy with medication Drug interactions between anticholinergics and: Beta-blocker Drowsiness Dizziness Confusion Blurred vision Amantadine Urinary retention Dry skim

  40. Interventions

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 5. Interventions-Sacral Neuromodulation- Side effects: • Skin irritation • Pain • Wire movement • Device problems • Interaction with other devices • MRI exam not possible

  48. 5. Interventions Surgery: • Bladder denervation • Bladderaugmentation • Bladder becomes enlarged with an extension made out of bowel • Larger reservoir with lower bladder pressures

  49. “I’ve reached that age where I’ve given up on Mind Over Matter and am concentrating on Mind Over Bladder.”

  50. 3. How to improve symptoms?Summary 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

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