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
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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3. How can I improve my symptoms?
-ExercisesPelvic floor exercise:
1. Helps strengthen the
muscles of the pelvic
floor – improves
bladder stability
Bladder
Relaxation
2. Helps suppress the
feeling of urgency
Contraction
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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.
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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
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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:
–Hypnotherapy
–Yoga
–Acupuncture
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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
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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
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4. Therapy with medication
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:
• 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.
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
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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 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
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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
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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
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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
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“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.
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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
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