1. health and fitness
2. disease
3. incontinence

Management of Neurogenic Bladder Disorders
Andrea Staack, MD, PhD
Pelvic Reconstructive Surgery,
Urinary Incontinence & Female Urology
Department of Urology
Loma Linda University, CA
Yes, it seems absolutely normal, that we all won’t share our urination
habits with our neighbor. Yes, it is even hard to address “peeing
problems” to our spouse, best friend or primary care taker.
That you can remain keeping this part of your privacy undisclosed, I
will step forward today and share my knowledge on the topic of
bladder problems with you.
FORMAL INTRODUCTION
Dear Ladies and gentlemen,
My name is Andrea Staack and I am pleased to be here today. I am a
Urologist specialized on patients suffering from a large spectrum of
voiding dysfunctions.
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 can you expect to learn during the next 20 minutes of this talk?
1.What is happing to my bladder?
2.How will I get evaluated?
3.How can I improve my symptoms?
4.Therapy with medication
5.Invasive interventions to treat neurogenic bladder disorders.
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
What is happening to my bladder?
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
“Your are not alone with bladder problems!”
40-50% in the elderly population will suffer from bladder disease in the
US. It is an extremely common problem among women and men.
It increases with age. Most people think incontinence is part of normal
aging.
Bladder problems can start out of the blue. Doctors call it idiopathic,
which means for no obvious reason or it can have a neurological cause.
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
Control of urination is dual under the influence of both the autonomic and central
nervous systems:
1.The autonomic nervous system control urination by direct nerve innervations to the
bladder coming from the spinal cord. Signals are sent back to the brain, when the
bladder is getting fuller.
2.The central nervous system controls bladder emptying voluntary, which allows for an
appropriate social setting for voiding, is voluntary.
The autonomic nervous system control and the central nervous system can be both
altered by aging or a 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
Patients with Friedeich’s ataxia might suffer from bladder disorders
with progression of the disease.
The exact mechanisms of what will happen is not clear. Degeneration
of peripheral nerves and the spinal cord, can have a different impact. It
can affect the bladder muscle or the sphincter muscles.
Overactive bladder. Damaged nerves may send signals to the bladder
at the wrong time, causing its muscles to squeeze without warning.
Urine retention. For some people, nerve damage keeps their bladder
muscles from getting the message that it is time to urinate or makes the
muscles too weak to completely empty the bladder. If the bladder
becomes too full, urine may back up and the increasing pressure may
damage the kidneys.
If urine remains in the body too long, an infection can develop in the
kidneys or bladder. Urine retention may also lead to overflow
incontinence—leakage of urine when the bladder is full and does not
empty properly.
Poor control of sphincter muscles. Sphincter muscles surround the
urethra—the tube that carries urine from the bladder to the outside of
the body—and keep it closed to hold urine in the bladder. If the nerves
to the sphincter muscles are damaged, the muscles may become loose
and allow leakage or stay tight when a person is trying to release urine.
Uncontrolled Contraction of the
Bladder Muscle
Normal bladder
Urethral resistance
Patients with urge
or frequency
Patients with urge
incontinence
Uncontrolled bladder
muscle contractions
7
Unstable Contraction of the Detrusor Muscle
- In healthy individuals, the urethral pressure is greater than the
bladder pressure
- In patients with frequency and urgency, unstable detrusor
contractions create the feeling of urgency, but incontinence does
not occur because the urethral pressure remains greater than the
bladder pressure
-In patients with urge incontinence, detrusor contractions are very
strong, resulting in an increase in bladder pressure that exceeds
urethral pressure; involuntary urine leakage occurs, often emptying
the bladder
Overactive Bladder
Part of the pathology of overactive bladder is the inappropriate contraction
of the detrusor muscle during the filling/storage phase
of the micturition cycle.
These unpredictable and involuntary detrusor contractions cause increased
urinary urgency, or a strong desire to urinate.
Because the bladder cannot fill appropriately or completely, bladder
capacity is reduced, resulting in urinary frequency, or the need to
empty the bladder frequently.
The most severe form of overactive bladder occurs when detrusor pressure
during these contractions overcomes sphincteric resistance, resulting in
urinary incontinence.
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
-More patients will most likely develop incontinence from bladder
overactivity than from difficulties to empty the bladder. In this talk I
will emphasize on on the most common symptoms complex and its
management and I will briefly talk about the management with
difficulties to empty the bladder.
-We know that Friedreich’s ataxia is a degenerative diseases of nerve
tissue in the spinal cord and the peripheral nerves.
-The exact mechanism of bladder disorders remains unclear at this
time.
1. What is happening to my bladder?
Overactive Bladder Symptom:
“Experiencing a strong urge to go to
the bathroom.”

Urinary Urgency
9
You might say: “I am expere….”
The symptoms of overactive bladder include
urinary urgency—the sudden, strong need to urinate
immediately
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
10
The symptoms of overactive bladder include
urinary frequency—urination eight or more times a day or two
or more times a night
1. What is happening to my bladder?
Overactive Bladder Symptom:
“Loosing involuntary urine accompanied with the
strong desire to void.”

Urge Urinary
Incontinence
11
The symptoms of overactive bladder include
urge incontinence—leakage of urine that follows a sudden,
strong urge to urinate
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
How will I get evaluated?
This information is key to learn about the type and the degree of the
bladder disorder. Which is essential to manage appropriately.
2. How will I get evaluated?
“Hello, incontinence helpline – Can you hold?”
I hope this won’t happen to you, when you are making your
appointment.
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.
14
At the beginning, a complete history needs to be obtained.
The urologist will ask about
-fluid intake
-number of continent and incontinent episodes
-night time urgency
-voiding pattern, such as quality of stream, or a feeling of incomplete
voiding
14
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
Further,
-alterations in bowel habits will be discussed
-changes in sexual function,
-An OB/GYN history will be obtained and
- a neurological history, including questions about back pain, back
surgery, stroke, numbness, weakness and balance problems.
15
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.
For more an objective quantification through a voiding diary needs to be conducted for
at least 24 consecutive hours.
In the the voiding diary you will beed to document
-the fluid intake,
-quantification of urine output with voiding hat
-documents uncontrolled loss of urine at day and night
-document the degree of urge to go to the bathroom
-and the use and number of pads.
16
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.
17
A thorough medical examination is mandated.
This includes a focused neurological examination, and
A rectal examination to rule out constipation, any growth or rectal
prolapse.
17
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
Urodynamic studies are very important.
They assess:
-uncontrolled bladder contractions
-urethral competence during filling
-Bladder function during voiding
-residual urine after urination.
Those information are crucial in understanding the pathology of the
disease in order to determine the best treatment for each individual
patient.
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
Urinalysis is an essential component of the patient workup and is
used to rule out conditions that may be responsible for such urinary
symptoms as urinary tract infection, cancer, diabetes, and renal
disease.
Blood work is also essential. A PSA test should be administered to
adequately informed men over 50 years of age in accordance with
the AUA guidelines.
Assessment of post void residuals needs to be performed. To learn
if the patient can empty the bladder. This can be done simply with
ultrasound or with catheterization.
19
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.
20
More invasive tests include:
-bladder scanning with a camera to rule out any growth inside the bladder,
inflammations or stones
Imaging studies can be obtained using ultrasound, x-ray with contrast
fluid, or MRI to evaluate the bladder, urethra and the pelvic floor.
20
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
After all this extensice work up and testing by your urologist, you will
be put to work!
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.
22
Fluid intake
-Amount of fluid <1500 cc, and in the older patients 15002000 cc/day of liquids
-too little: smaller amounts of fluid intake results in smaller
amounts of urine, which is higher concentrated and
irritates the bladder. Patients are also more prone to
urinary tract infections.
22
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.
23
It is also important to watch out what to drink.
Caffeine:
-natural diuretric and bladder irritant
-can cause bladder spasms
Alcohol:
-has an diuretric effect (causes release of anti-diuretic
hormone from the pituitary gland)
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
Now, think about foods.
Certain foods are high in Vit. D, B, protein and potassium.
This has been shown to be bladder protective for
overactivity.
Other Foods, such as
-Artificial sweeteners (e.g. aspartame)
-highly spiced foods
-chocolare
are more likely prone to increase bladder spasms.
---Little scientific evidence exists on certain foods and little
research has been done so far-My goal is to increase awareness in my patients to
consider an effect on the bladder with certain foods
Bowel regulation:
-straining and constipation can induce progressive
neuropathy
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
In addition to dietary changes, lifestyle changes have been shown to
protect the bladder and to decrease overactive episodes.
1.Quit smoking.
This reduces the risk of chronic coughing. Coughing puts on extra
downward pressure on the pelvic floor.
2. Weight reduction might be considered.
Excessive body weight affects the bladder pressure, blood flow, and
nerves.
25
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
26
Exercise for the pelvic floor can be very helpful to deal with bladder overactivity.
It
1.Helps to strenghten the muscles of the pelvic floor and improves bladder stability
2.It helps to suppress the feeling of urgency.
26
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.
27
How can I do pelvic floor exercise. You might have heard about Kegel
exercise. It is very effective for women AND men. Now, I will put you to
work. Everybody is asked, because people, who haven’t found tehmself
from having bladder problems, might will from this exercise, since it is
preventative
Start by locating your PC muscle.
Many people begin doing kegel exercises but are actually squeezing the
wrong muscle. Before you start the exercises, find your PC muscle, make
sure you know where your PC muscle is and what it feels like.
Squeezing kegel exercises: start slow, find your baseline.
The basic exercise can be done anytime and anywhere. Just squeeze your
PC muscles as hard as you can, and hold them. This is doing a kegel
exercise. Start by squeezing and holding for a count of 3-5 seconds, then
release and relax for 5 seconds. When you release, notice how your
muscles feel. The first time you do a kegel exercise see how many times
you can do it before you feel your muscles getting tired.
Squeezing kegel exercises: use sets of repetitions
Your kegel exercises will be most efficient and have the most impact if
you get into doing sets of repetitions of the squeezing. Once you’ve found
your baseline, you can work from there. If you can, start with doing 5
repetitions (squeeze/hold/release). Judge for yourself how long you can
hold the squeeze for, but don’t push yourself too much at first.
Building up strength with kegel exercises.
Once you've found your baseline, do your exercises, and every couple of
days increase both the length of time you hold the squeeze for, and the
number of exercises per set. As a guideline, try to work up to a point
where you can hold the squeeze for ten seconds. And try to work up to
27
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
28
In case you feel lost practicing KEGEL exercise or finding the
right muscles to contract, you might consider Biofeedback. IT
Biofeedback therapy monitors the correct muscluar contraction to
develop conscious control of pelvic musculature.
If you are able to perform a voluntary contraction of the pelvic
floor muscles, you might be better in controling the urge to
urinate.
--------Outpatient clinic, 4-8 hours/week
-relaxing environment
-Measurment of bladder pressure, anal sphincter pressure and
vaginal EMG plust measurment of abdominal activity
-rectal ballon for intra-abdominal pressure
-First step is to make the patient understanding to identify the
PFM when instructed to squeeze around the examiners fingers,
lifting up (some patients bear down, which is counter productive,
it increases intra-abdominal pressure
-Patients are instructed to breath evenly and to relax abdominal
muscles
-Place one hand on the abdomen to notice faulty abdominal
contractions
28
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
29
By training your pelvic floor muscles you have already
excelled. Now it is time to train your bladder.
This is the way you can do it:
1.Schedule voiding at set times during the day
2.Use actively your trained pelvic floor msucles to prevent urine
leakges
3.Increase your voding intervals after the nital goal is achieved.
4.Keep your own input and output chart
5.Reward yourself, when you noticed that you urinated more but
less frequently.
29
3. How can I improve my symptoms?
Alternative therapies:
–Hypnotherapy
–Yoga
–Acupuncture
30
Hypnosis
-Form of cognitive therapy
-Hypnotherapy teaches patients through relaxation and suggestion to
regain the executive function of the brain over the bladder’s afferent
signals to urinate.
-Provides relaxations techniques
Yoga:
-also provides relaxation techniques and strengthen the pelvic floor
Acupuncture
-Inhibits uncontrolled bladder contractions
-studies have shown that acupuncture effects the PFM
30
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
31
Behavioral modification plus exercise provides plus bladder training
are excellent treatments with minimal side effects to control bladder
overactivity.
Patients should be instructed to implement the following program
at home:
regular pelvic floor muscle exercises
specified voiding schedule aimed at expanding voiding
intervals
guidelines for controlling urgency
active use of muscles to prevent urine loss
Program to train yourself at
home:
1.Regular pelvic floor muscle
exercises
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
If those measurements are not sufficient to improve symptoms, there
are some forms of medical therapy. However, if possible, I recommend
medication only in conjunction with life style changes, dietary changes,
and the exercises.
“Each capsule contains your medication
plus a treatment for each of its side effects.”
Those pills are not on the market yet, since nobody is able to swallow
them.
4. Therapy with medication
Drug Treatment for Overactive Bladder:
• Targets bladder nerves to block uncontrolled
contractions
– Anticholinergics

Not very bladder specific
34
Drug treatment for overactive bladder symptoms is problematic.
It focuses on blocking receptor sides at the bladder, but is not very bladder specific.
Blocking those receptors creates side-effects, and additional, not pleasant drug
interactions can occur, if you are on medications for ataxia.
34
4. Therapy with medication
Side effects:
• Dry mouth
• Tachycardia
• Constipation
• Fatique
• Blurred vision
• Dizziness
• Slow thinking
35
Therefore, side effects are common:
-The clinical usefulness of previous therapies for OAB was limited by
anticholinergic side effects in other body systems because these agents
are not selective for the bladder.
-The most bothersome side effects of the class of anticholinergics include
dry mouth, constipation, blurred vision, tachycardia, and impaired
cognitive function. These side effects are more pronounced in elderly
patients.
35
4. Therapy with medication
Drug interactions between anticholinergics and:
• Beta-blocker
• Drowsiness
• Dizziness
• Confusion
• Blurred vision
• Amantadine
• Urinary retention
• Dry skim
36
Watch out, when your take other medications .
-The clinical usefulness of previous therapies for OAB was limited by
anticholinergic side effects in other body systems because these agents
are not selective for the bladder.
-The most bothersome side effects of the class of anticholinergics include
dry mouth, constipation, blurred vision, tachycardia, and impaired
cognitive function. These side effects are more pronounced in elderly
patients.
-Thus, the ideal antimuscarinic agent for the treatment of OAB would be
one that acted specifically on the detrusor muscarinic receptors.
36
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
If behavioral changes and medications don’t work, there are some
alternatives. They are more or less invasive.
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
38
or Botox. It is pretty effectful to treat wrinkles,
but it can also do good for your bladder.
You might have heard about Botulinum toxin
First of all, your urologist needs to rule out that you suffer from urinary retention,
because Botox could makes things worse.
If this is not the case, than it gets directely injected into your bladder. It works like a
chemical denervations, and starts already improving symptoms as early as 2 days after
injections.
----BTX - neurotoxin produced by Clostridium botulinum and is a potent presynaptic
inhibitor of acetylcholine release at the neuromuscular junction
-It is applied directly by cystoscopic injection into the detrusor muscle, producing a
chemical denervation that is reversible after approximately 6 months (up to 9)
-The mode of administration allows high concentrations of the agent to reach the
bladder tissue without systemic administration and resultant unsuitable levels in other
organs
-BTX is not approved for the treatment of OAB but is now widely used in patients
who are refractory to conventional antimuscarinic therapy or who do not tolerate it
due to systemic side effects.
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
39
Botox lasts between 3-6 months.
It is not FDA-approved for neurogenic bladder disorders, but widely used worldwide,
when medications fails
But watch out, if you are having difficulties emptying your bladder.
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
Botulinum toxin
The local side effects are:
-Excessive bladder muscle relaxation, what can cause urinary retnetion
-Pain
-Infections
-Bleedings
General:
Muscluar weakness
I might become less effective using it for a long time
Building up a resistance
40
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
least invasive forms of neuromodulation used to treat overactive bladder (OAB) and the
associated symptoms of urinary urgency, urinary frequency and urge incontinence
The needle electrode is then connected to an external pulse generator which delivers an
adjustable electrical pulse that travels to the sacral plexus via the tibial nerve. Among other
functions, the sacral nerve plexus regulates bladder and pelvic floor function.
Percutaneous tibial nerve stimulation (PTNS)
-Non-invasive way of modulating pelvic reflexes via projections from the posterior
tibial nerve
-is used to deliver stimulation to the posterior tibial nerve using a very thin needle like
used for acupuncture
-The recommended course of treatment is 12 weekly sessions of 30 minutes each
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
42
Sacral neuromodulation is well established as a treatment for urgency, frequency,
urge UI, and urinary retention
The complete mechanism of action remains unknown but theories include modulation
of spinal cord reflexes and brain networks primarily via somatic sensory afferent
fibers
In addition, previously excluded patients such as those with neurologic diseases like
multiple sclerosis or Parkinson's disease and patients with incomplete spinal cord
injuries are now undergoing SNM with good success.
There are no data on patients with ataxia, who underwent sacral neuromodulation.
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
43
Sacral neuromodulation is well established as a treatment for urgency, frequency,
urge UI, and urinary retention
The complete mechanism of action remains unknown but theories include modulation
of spinal cord reflexes and brain networks primarily via somatic sensory afferent
fibers
In addition, previously excluded patients such as those with neurologic diseases like
multiple sclerosis or Parkinson's disease and patients with incomplete spinal cord
injuries are now undergoing SNM with good success.
There are no data on patients with ataxia, who underwent sacral neuromodulation.
5. Interventions
-Sacral NeuromodulationSide effects:
– Skin irritation
– Pain
– Wire movement
– Device problems
– Interaction with other devices
– MRI exam not possible
44
Sacral neuromodulation is well established as a treatment for urgency, frequency,
urge UI, and urinary retention
The complete mechanism of action remains unknown but theories include modulation
of spinal cord reflexes and brain networks primarily via somatic sensory afferent
fibers
In addition, previously excluded patients such as those with neurologic diseases like
multiple sclerosis or Parkinson's disease and patients with incomplete spinal cord
injuries are now undergoing SNM with good success.
There are no data on patients with ataxia, who underwent sacral neuromodulation.
5. Interventions
Surgery:
• Bladder denervation
• Bladder augmentation
– Bladder becomes enlarged with an extension made out
of bowel
– Larger reservoir with lower bladder pressures
45
The last resort is surgery. In very severe cases the
Bladder can become disconnected from their nerves,
It can get augmented. That means with own bowel a cap or pouch can be created and
can enlarge the bladder. A larger reservoir will be made this way with lower pressures
Last but not least, your bladder matters!
I want to increase awareness of neurogenic bladder disorders in you as
patients and want you to understand how the diagnosis made and
how to mange those bladder problems.
If there is anything wrong with your bladder; you know, now, that
1.You are not alone with this problem,
2.You can feel less embarrassed to address it and
3.You have learned that you can change the way it is.
I am happy to answer your questions in a little bit.
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
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Among the symptom complex of Freidreich’s ataxia exist neurogenic
bladder disorders.
Most patients, who suffer form neurogenic bladder disorders, have
been diagnosed with overactive bladder symptoms.
With progression of the disease or simply with aging, about 50% of
patients with Friedreich’s ataxia develop urgency, frequency or urge
urinary incotniencne. The symptoms usually appear not before 10
years of the onset of the disies
The exact mechanism of developing overactive bladder symptoms
remains not clear at this time. But we know, it is a degenerative disease
of the spinal cord and also the peripheral nerves. Nerves, which
innervate the bladder might be involved during the progression of this
disease.
Overactive bladder. Damaged nerves may send signals to the bladder
at the wrong time, causing its muscles to squeeze without warning. The
symptoms of overactive bladder include
urinary frequency—urination eight or more times a day or two
or more times a night
urinary urgency—the sudden, strong need to urinate
immediately
urge incontinence—leakage of urine that follows a sudden,
strong urge to urinate
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.
Secondary causes for bladder disorders need to be excluded:
Such as:
-diabetes, which causes also peripheral nerve damages
-Congestive heart failure, which might cause edema. Can lead to more
urination during the night.
-bladder cancer or urinary tract infections, can cause irritation
-pregnancy can lead to bladder overactivty as well as certain
-medications.
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.
Normal voiding Cycle
This diagram shows you a normal voiding cycle. I will walk you through.
The normal voiding cycle is comprised of a filling/storage phase and an emptying phase.
1.During the filling phase, the bladder muscle stretches to maintain low pressure. At the
same time, the urethral sphincter is under high pressure. Sensation of bladder fullness
begins when the bladder is half full at around 250cc.
2.At around 500cc, an individual experiences a strong desire to void and the emptying
phase begins.
3.After a person chooses the right place to urinate, the urethral sphincter voluntarily
relaxes, the pelvic floor relaxes and the bladder muscles contracts. Urination is
happening!
4.After this is done, the cycle resumes with bladder filling, urethral sphincter and pelvic
floor tightening and bladder muscle relaxation.
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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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Medications That May Influence Bladder Function
Those medications, which might influence bladder functions and
might caus overactive bladder-like symptoms are:
diuretics
antidepressants
antihypertensives
hypnotics
analgesics
narcotics
sedatives
OTC sleep aids and cold remedies
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.”
“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
In order to understand the significance of the problem, the urologist will need to
quantify the symptoms.
The following questions will be asked through validated questionnaires:
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?
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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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The examine the genitalia and the perineum, which is the bicycle seat
area is very important.
The physician will evaluate for prolapse disease, of organs like the
bladder, the uterus or the vagina fall out the pelvis.
The skin of the vagina will be evaluated for thinning.
Through a cough test, the urethral shincter muscle will be evaluated. If
there is less support, there might be leakage noticed during coughing.
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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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How can you change your bladder symptoms yourself.
Here are some tips on a program to train yourself at home:
1.Perform regular Kegel exercise to train your pelvic floor muscles
2.Set up a voiding schedule to aim to expand voiding intervals. If
you were able to hold urine for 40 min, than start to hold for 5
min longer for a couple of days and increase it. After 2 weeks
you might see yourself being able to hold urine for longer than
60 mins and so on.
3.Use actively your pelvic floor muscles to prevent urine loss.
4.Apply dietary changes. Watch out for caffeinated drinks or
excessive fluid intake!
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