Cerebral Palsy Neurogenic Bladder, Outcomes of Lifetime Care · Murphy KP, et al. Cerebral Palsy,...

Gillette North

Cerebral Palsy 1

Cerebral Palsy Cerebral Palsy

NeurogenicNeurogenic Bladder, Bladder,

Outcomes of Lifetime Outcomes of Lifetime

CareCare

Kevin P Murphy MDKevin P Murphy MD

Gillette Lifetime Specialty HealthcareGillette Lifetime Specialty Healthcare

St. Paul MinnesotaSt. Paul Minnesota

Gillette North

Cerebral Palsy 2

Disclosure Information Disclosure Information

AACPDM 67AACPDM 67’’th Annual Meeting, th Annual Meeting,

October 16October 16--19, 201319, 2013

�� I have no financial relationships to discloseI have no financial relationships to disclose

�� I will discuss the following off label use and/or I will discuss the following off label use and/or

investigational use in my presentation:investigational use in my presentation:

�� Clostridium Clostridium BotulinumBotulinum Toxin A injections for Toxin A injections for

urinary incontinence in adults with cerebral palsy. urinary incontinence in adults with cerebral palsy.

Gillette North

Cerebral Palsy 3

Cerebral PalsyCerebral Palsy--NeurogenicNeurogenic BladderBladder

�� 1. McNeal DM, et al. DMCN 1983; 5: 6121. McNeal DM, et al. DMCN 1983; 5: 612--6.6.

�� 2. 2. DectorDector RM, et al. J RM, et al. J UrolUrol 1987; 138: 11101987; 138: 1110--2.2.

�� 3. 3. DrigoDrigo P, et al. Ital J P, et al. Ital J NeurolNeurol SciSci 1988; 9:1511988; 9:151--4.4.

�� 4. Mayo ME. J 4. Mayo ME. J UrolUrol 1992; 147: 4191992; 147: 419--20.20.

�� 4. Reid CJ, et al. Arch 4. Reid CJ, et al. Arch DisDis Child 1993; 68: 739Child 1993; 68: 739--42.42.

�� 5. 5. HouleHoule AM, et al. J AM, et al. J UrolUrol 1998; 160: 10881998; 160: 1088--91. 91.

�� 6. 6. KaramanKaraman M, et al. M, et al. IntInt J J UrolUrol 2005; 12: 7172005; 12: 717--20.20.

�� 7. Silva JA, et al. Urology 2010; 76: 9427. Silva JA, et al. Urology 2010; 76: 942--5.5.


�� BorzyskowskiBorzyskowski M. Cerebral Palsy and the Bladder. M. Cerebral Palsy and the Bladder.

DMCN 1989; 31: 697DMCN 1989; 31: 697--9.9.

�� Many factors involved with bladder control in people Many factors involved with bladder control in people

with cerebral palsy.with cerebral palsy.

�� Factors include: age, cognition, communication, Factors include: age, cognition, communication,

mobility, UE function, expectations, training, mobility, UE function, expectations, training,

hypertonicityhypertonicity and compatible living environment. and compatible living environment.

�� Continence more complicated than static CNS Continence more complicated than static CNS

pathology & measured bladder function. pathology & measured bladder function.

Gillette North

Cerebral Palsy 4

Cerebral PalsyCerebral Palsy--NeurogenicNeurogenic BladderBladder�� Murphy KP, et al. Cerebral Palsy, Murphy KP, et al. Cerebral Palsy, NeurogenicNeurogenic Bladder & Bladder &

Outcomes of Lifetime Care. DMCN 2012; 54: 945Outcomes of Lifetime Care. DMCN 2012; 54: 945--50. 50.

�� 214 people with CP seen in sequence through an 214 people with CP seen in sequence through an

outpatient Rehabilitation Medicine clinic. outpatient Rehabilitation Medicine clinic.

�� 96 females, 118 males. GMFCS levels I 96 females, 118 males. GMFCS levels I –– V. V.

�� 52 with 52 with hemiplegiahemiplegia, 42 , 42 diplegiadiplegia, 117 , 117 quadraplegiaquadraplegia, 3 , 3

dyskinesiadyskinesia ((athetosisathetosis component).component).

�� Median age for total population 9.6 years (ages 5Median age for total population 9.6 years (ages 5--66). 66).

�� Special education levels through graduate school.Special education levels through graduate school.


�� 16.4% (35 individuals) with symptomatic 16.4% (35 individuals) with symptomatic neurogenicneurogenic

bladder (SNB) on bladder (SNB) on urodynamicurodynamic testing.testing.

�� 91% obtained total continence or major improvement 91% obtained total continence or major improvement

(drops in urinary pads only) with conservative care. (drops in urinary pads only) with conservative care.

�� Prevalence of males to females with SNB equal. Prevalence of males to females with SNB equal.

�� SNB documented across the lifespan, educational SNB documented across the lifespan, educational

spectrum and functional levels.spectrum and functional levels.

�� More common in those with bilateral involvement.More common in those with bilateral involvement.

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Cerebral Palsy 5


�� 80% with spastic hyper80% with spastic hyper--reflexicreflexic type on type on

urodynamicurodynamic testing (International Continence testing (International Continence

Society Criteria 2010). Society Criteria 2010).

�� Tendency for urinary retention and hypoTendency for urinary retention and hypo--reflexiareflexia

in the adult over 30 years old (GMFCS Level V).in the adult over 30 years old (GMFCS Level V).

�� Upper urinary tract pathology infrequent.Upper urinary tract pathology infrequent.

�� Small spastic bladder in child may overstretch Small spastic bladder in child may overstretch

into larger hypointo larger hypo--reflexive bladder of adult. reflexive bladder of adult.


�� May be the May be the most common missed diagnosismost common missed diagnosis

(associated condition) in the care of people with CP.(associated condition) in the care of people with CP.

�� One of the One of the most easily treated problemsmost easily treated problems in in

people with CP.people with CP.

�� A problem of Lifetime CareA problem of Lifetime Care-- more apparent in the more apparent in the

adult but with often undiagnosed roots in adult but with often undiagnosed roots in

childhood. childhood.

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Cerebral Palsy 6


�� Individual Selection CriteriaIndividual Selection Criteria

�� Basic and consistent yes/no communication Basic and consistent yes/no communication

system in place.system in place.

�� Personal desire to be dry, more continent Personal desire to be dry, more continent

and out of pads if possible.and out of pads if possible.

�� Functional Toileting Environment (FTE), is Functional Toileting Environment (FTE), is

present or can be created.present or can be created.

Functional Toileting Environment (FTE)Functional Toileting Environment (FTE)

�� An environment allowing toileting to occur in An environment allowing toileting to occur in

a continent & functional manner, including a continent & functional manner, including

necessary communications, staffing, necessary communications, staffing,

equipment and motivation. equipment and motivation.

�� Can involve full medical and surgical team Can involve full medical and surgical team

review including Occupational, Physical & review including Occupational, Physical &

Speech therapy, social services, psychology Speech therapy, social services, psychology

and nursing support. and nursing support.

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Cerebral Palsy 7

Functional Toileting Environment (FTE)Functional Toileting Environment (FTE)

�� Private environmentPrivate environment

�� Public environmentPublic environment

�� FriendFriend’’s homes home

�� Family homeFamily home

�� OutdoorsOutdoors

�� IndoorsIndoors

�� UpstairsUpstairs

�� DownstairsDownstairs

FTEFTE-- Therapeutic InterventionsTherapeutic Interventions

�� AugmentiveAugmentive communication devicecommunication device--DynavoxDynavox/IPAD/IPAD

�� Floor Reaction AFO / LFloor Reaction AFO / L--CrutchesCrutches

�� Grab bars/space to perform transfersGrab bars/space to perform transfers

�� ITB/Botox/Phenol: ITB/Botox/Phenol: egeg hip adductorship adductors

�� Adaptive commode/time to sit alone in privacyAdaptive commode/time to sit alone in privacy

�� Staffing assist and education that Staffing assist and education that ““can be donecan be done””. .

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Cerebral Palsy 8


�� Treatment Options outside of FTETreatment Options outside of FTE

�� AnticholinergicsAnticholinergics

�� Management of pelvic floor Management of pelvic floor hypertonicityhypertonicity

including hip adductors.including hip adductors.

�� Fluid schedulesFluid schedules

�� Catheterization options (ICC, Indwelling)Catheterization options (ICC, Indwelling)

�� Surgical optionsSurgical options


�� Diagnostic TestingDiagnostic Testing

�� Computerized Functional Computerized Functional UrodynamicUrodynamic StudyStudy

�� Voiding Voiding CystoCysto UrethrogramUrethrogram (VCUG)(VCUG)

�� Renal Bladder Ultrasound (RBUS)Renal Bladder Ultrasound (RBUS)

�� Urine analysis &/or culturesUrine analysis &/or cultures

�� Metabolic profile (electrolytes, BUN & Metabolic profile (electrolytes, BUN & creatininecreatinine))

�� Vitamin B 12Vitamin B 12

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Cerebral Palsy 9


�� Reasons for Failed Treatment Reasons for Failed Treatment

�� Cognitive deficiencyCognitive deficiency

�� Behavioral deficiencyBehavioral deficiency

�� Mental Health diagnosesMental Health diagnoses

�� Sexual abuseSexual abuse

�� PsychoPsycho--Social issues (Social issues (egeg parents separated, living parents separated, living

in different homes with ongoing discord). in different homes with ongoing discord).


�� Adult who now becomes incontinentAdult who now becomes incontinent

�� Primary Condition (incontinence not in CP Primary Condition (incontinence not in CP defintiondefintion))

�� Secondary conditions (over stretched bladder now Secondary conditions (over stretched bladder now

with retention & leaking; cervical spinal with retention & leaking; cervical spinal stenosisstenosis).).

�� Associated conditions (seizures, late onset Associated conditions (seizures, late onset dystoniadystonia). ).

�� ComorbiditiesComorbidities (stress incontinence; interstitial (stress incontinence; interstitial

fibrosis; tumors; Alzheimerfibrosis; tumors; Alzheimer’’s/CNS degeneration). s/CNS degeneration).

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Cerebral Palsy 10


�� Continence of urine; a part of basic human dignity.Continence of urine; a part of basic human dignity.

�� Should not be denied anyone within context of Should not be denied anyone within context of

patientpatient--centered professional medical/surgical care.centered professional medical/surgical care.

�� Further study & research in the urinary continence of Further study & research in the urinary continence of

people with CP is hoped & called for at this time.people with CP is hoped & called for at this time.

�� Encouragement is given to facilitate Lifetime Care Encouragement is given to facilitate Lifetime Care

medical & surgical practices for this problem of medical & surgical practices for this problem of

young & old. young & old.

Gillette North

Cerebral Palsy 11

Cerebral Palsy Neurogenic Bladder, Outcomes of Lifetime Care · Murphy KP, et al. Cerebral Palsy,...

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