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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

NeurogenicBladder Disorders

Dr MalithKumarasinghe

MBBS (Colombo)

what will you learn during the 2 hours
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
slide3
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
normal voiding cycle
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.

slide5
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

uncontrolled contraction of the bladder muscle
Uncontrolled Contraction of the Bladder Muscle

Normal bladder

Patients with urge or frequency

Patients with urge incontinence

Urethral resistance

Uncontrolled bladder muscle contractions

slide8
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
slide9

Overactive Bladder Symptom:

  • “Experiencing a strong urge to go to the bathroom.”
  •  Urinary Urgency
slide10

Overactive Bladder Symptom:

    • “Going to the bathroom frequently.”
  • “Have to go to the bathroom, where the bladder wakes me up at night.”
  •  Urinary Frequency
slide11

Overactive Bladder Symptom:

  • “Loosing involuntary urine accompanied with the strong desire to void.”
  •  Urge Urinary Incontinence
slide12

2. How to evaluate?

“Hello, incontinence helpline – Can you hold?”

2 how to evaluate history
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.

2 how will i get evaluated history
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

2 how to evaluate history1
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.

2 how to evaluate history2
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
2 how will i get evaluated
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
2 how to evaluate quantification of symptoms
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.

2 how to evaluate quantification of symptoms1
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

2 how to evaluate physical examination
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.

2 how to evaluate invasive tests
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.

slide22

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.

2 how to evaluate invasive tests1
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.

dietary changes
-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.

dietary changes1
-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.

dietary changes2
-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.

lifestyle changes
-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.

exercises
Helps strengthen the muscles of the pelvic floor – improves bladder stability

Helps suppress the feeling of urgency

Bladder Relaxation

-Exercises-

Pelvic floor exercise:

Contraction

e xercises
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.
3 how to improve symptoms
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
slide32
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
slide33
Alternative therapies:
  • Hypnotherapy
  • Yoga
  • Acupuncture
4 how to improve symptoms summary
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
what will you learn during the next 20 min
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
4 therapy with medication
4. Therapy with medication

Drug Treatment for Overactive Bladder:

Targets bladder nerves to block uncontrolled contractions

Anticholinergics

 Not very bladder specific

4 therapy with medication1
4. Therapy with medication

Side effects:

Dry mouth • Tachycardia

Constipation • Fatique

Blurred vision • Dizziness

Slow thinking

4 therapy with medication2
4. Therapy with medication

Drug interactions between anticholinergics and:

Beta-blocker

Drowsiness

Dizziness

Confusion

Blurred vision

Amantadine

Urinary retention

Dry skim

5 interventions botox
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
5 interventions botox1
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
5 interventions botox2
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
5 interventions electrical stimulation of the tibial nerve
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
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
5 interventions sacral neuromodulation1
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
5 interventions sacral neuromodulation2
5. Interventions-Sacral Neuromodulation-

Side effects:

  • Skin irritation
  • Pain
  • Wire movement
  • Device problems
  • Interaction with other devices
  • MRI exam not possible
5 interventions
5. Interventions

Surgery:

  • Bladder denervation
  • Bladderaugmentation
    • Bladder becomes enlarged with an extension made out of bowel
    • Larger reservoir with lower bladder pressures
slide49

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

Mind Over Matter and am concentrating on

Mind Over Bladder.”

3 how to improve symptoms summary
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