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Neurogenic bladder in patients with spinal cord

lesion

JJ Wyndaele MD DBMSci PhD FEBU FISCOS

2007

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Myelodysplasia 90% -97% (Smith 1965)

Spinal stenosis 61-62% (Tammela et al 1992, Kawaguchi 2001)

Spine surgery 38%-60% (Boulis et al 2001, Brooks, ME 1985)

Disc disease 28%-87% (Bartolin et al 1999, O’Flynn et al 1992)

Spinal cord injury ? majority

Prevalence neurogenic bladder in spinal lesion

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History

05

101520253035404550

1961 1968 1973 1983

urorenalmortality%

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UK survey GPRD• Increased risk renal failure paraplegia

versus general population

1994 x 7.51995 x 81996 x 5.91997 x 3.5

Lawrenson, Wyndaele, Vlachonikolas, Farmer, Glickman Neuroepidemiology 2001; 20: 138-143

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Bladder management

• Life

• Quality of life

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Management neuro-urology after spinal cord lesion

• Prevent deterioration of the kidneys

= permit to survive

• Prevention of incontinence and infection

= permit a good life

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S2S3S4

Innervation lower urinary tract

T10-L1

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Neurogenic ActionsSym PSym Som

Bladder - +

Bladder neck

+ -

Extern US (?) (?) +

Pelvic floor +

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S2S3S4

Neuropathy lower urinary tract

T10-L1

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Status upper tract depends greatly on

function of lower tract

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Importance of

intravesical pressure

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• Pressure development during filling

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• Pressure development during filling

• Pressure development during voiding

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SCL Urinary Function

1. Spinal shock bladder

2. Diagnosis type neurogenic bladder

3. Treatment - rehabilitation

4. Follow-up

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1. Spinal shock bladder

• Bladder drainage– intermittent catheterization– suprapubic catheter– indwelling transurethral catheter

• Avoid overdistention and infection

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2. Urologic Diagnosis

• Urodynamic function • Status upper tract• Other complications

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Diagnosis

• Most tests as used in non neurogenic: History, clinical examination and neurourologic testing, urine test, renal function

Voluntary control of anal sphincter and

perineal muscles

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Combination of these data permits a fairly accurate diagnosis of

completeness, detrusor function and sphincter function

in up to 80 %

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Clinical observation is very important

• Spontaneous voiding• Leakage when moving• Smelly urine, Fever and

other signs of infection• Calculi evacuated• et al

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Diagnosis

• Urodynamic investigation: cornerstone of the diagnosis and prognosis. Preferably video urodynamics

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Main types of LUT neuropathy in SCL

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Further diagnostics

• Ultrasound

• Endoscopy

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Expectations of management

Rehab team

1. Kidneys safe

2. No complications

3. Continent

4. Affordable

Patient

1. Continent

2. No complications

3. Affordable

4. Kidneys safe

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Conservative treatment neurogenic bladder

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Conservative treatment overview

• Behavioural therapyB.1 Behavioural methods Toiletting assistanceB.2 Triggered reflex voidingB.3 Bladder expression (Crede and Valsalva manouvre)

• CathetersC.1 Intermittent catheterisationC.2 Indwelling catheterisationC.3 Condom catheter and external appliances

• Pharmacotherapy

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Behavioural methods

• Scheduled voiding• Consecutive voids• Increased interval• Drinking habits• Toilet accessibility• Patient’s mobility• Keeping voiding diary

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Triggered voiding and Valsalva-Crede voiding

• Prove first urodynamically safe:

Basically dangerous methods.

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Intermittent catheterisation

• First choice of treatment

• Proper education and teaching necessary.

CIC

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Pharmacological treatment

• Decrease bladder overactivity• Anti bacterial• Peroral, Intravesical instillation,

transdermal, transrectal

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Indwelling catheters

• Short-term ID during the acute phase

• Transurethral ID not safe for long-term use

in neuropathic patients

• Bladder screening for bladder cancer is

mandatory especially in those with ID/SC more than 5-10 years.

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Suprapubic catheter

Less urethral complications

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Condom Catheter

• Long-term use does not increase the risk of UTI

• Complications less if good hygiene care, frequently change CC and low bladder pressures.

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Surgery neurogenic bladder

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Surgery to increase detrusor contractility + abolish reflex

activity• SARS + Dorsal Rhizotomy

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Possible alternatives to avoid rhizotomy: under research

• Selective anodal block• Cryotherapy deafferentation• SPARSI (anterior + posterior rooths)

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Surgery decrease outlet resistance

• TUI sphincter • Intraurethral stents • Botulinum Toxin

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Surgery to lower detrusor contractility – intravesical pressure

• Botulinum Toxin in detrusor

• Enterocystoplasty

• Autoaugmentation

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Surgery to increase sphincter resistance

• Artificial urinary sphincter

• Sling procedures

• Resorbable or non –resorbable bulking agents

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Diversion

• Acceptable treatment in selected cases

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Future ?

• Restoring function by nerve transplants?

• Cell therapy ?• Stem cell therapy ?

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4. Follow-up

• Lifelong every 1 – 2 years• Must include

– Imaging UT / function UT– Urine– Blood– (Urodynamics)

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Quality of life (meta-analysis)

• SCI significantly lower in all subscales compared with normative population

• Neurogenic pain, spasticity, and neurogenic bladder and bowel problems give lower QL scores.

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Quality of life in primary caregivers (meta-analysis)

• significantly lower compared to age-matched healthy population based controls

• No significant relation was demonstrated with the duration of injury, lesion levels, ASIA scores, degree of spasticity, bladder and/or bowel incontinence and pressure sores respectively.

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Causes for readmission

• “The leading cause of rehospitalization are diseases of the genitourinary system, including urinary tract infections”

• Cardenas et al Arch Physic Med Rehab 2004

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Do spinal cord injury patients always get the best treatment for

neuropathic bladder after discharge from regional spinal injuries centre?

Vaidyanathan et al Spinal Cord 2004

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Conclusions

• Urinary problems less dangerous for life expectancy than some decades ago

• Follow up life long• Urinary problems still very much

influencing quality of life• Bladder management cross-

disciplinary work• Patient is central• Do not forget relatives

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Thanks for listening