management of neurogenic bladder disorders andrea staack, md, phd pelvic reconstructive surgery,...
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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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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. Simple measurements for therapySimple measurements for therapy
4.4. Therapy with medicationTherapy with medication
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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1. What is happening to my bladder?
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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1. What is happening to my bladder?
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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1. What is happening to my bladder?
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Overactive Bladder Symptom:
“Experiencing a strong urge to go to the bathroom.”
Urinary Urgency
1. What is happening to my bladder?
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Overactive Bladder Symptom:
“Going to the bathroom frequently.”
“Have to go to the bathroom, where the bladder wakes me up at night.”
Urinary Frequency
1. What is happening to my bladder?
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Overactive Bladder Symptom:
“Loosing involuntary urine accompanied with the strong desire to void.”
Urge Urinary Incontinence
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. Simple measurements for therapySimple measurements for therapy
4.4. Therapy with medicationTherapy with medication
5.5. Forms of interventionsForms of interventions
2. How will I get evaluated?-History-
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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2. How will I get evaluated?-History-
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 symptoms-
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-
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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2. How will I get evaluated?
-Invasive Tests-
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-
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 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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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. Forms of interventionsForms of interventions
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
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. 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-
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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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
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3. How can I improve my symptoms?
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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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. Forms of interventionsForms of interventions
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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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4. Therapy with medication
Side effects: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: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?
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. 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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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. 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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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: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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1. What is happening to my bladder?
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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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.
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.
2. How will I get evaluated?
• 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.”
2. How will I get evaluated?-Quantification of symptoms-
2. How will I get evaluated?-Quantification of symptoms-
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
2. How will I get evaluated?-Physical examination-
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