1. health and fitness
2. disease
3. incontinence

Ad
Advance Practice P ti
Management of
Management of Neurogenic Bladder
Diane K. Newman, DNP, ANP
Diane K Newman DNP ANP‐
ANP‐BC, FAAN
BC FAAN
Co‐Director, Penn Center for Continence and Pelvic Health
Co‐
Division of Urology, University of Pennsylvania Health System Adjunct Associate Professor of Urology in Surgery
Research Investigator Senior, Perelman School of Medicine
Philadelphia, Pennsylvania
Philadelphia, Pennsylvania
Voiding
and Wiring
Voiding ‐‐ Plumbing
Plumbing and Wiring
Mechanical And Electrical (Neurological)
g
Physiology
of the Bladder
Physiology of the Bladder
» Bladder functions
○ Storage (mainly)
○ Emptying of urine
Emptying of urine
Andersson K‐E. Pharmacol Rev. 1993;45:253‐307.
;
Lower Urinary Tract Function:
Urine Storage and Release
Urine Storage and Release
Reservoir
Bladder
Urethra
Striated external
urethral sphincter (EUS
(EUS))
Outlet
V l
Valve
(Storage – closed)
((Release – open))
Storage Problem: Incontinence
Normal (no incontinence)
ƒ Large Large capacity, relaxed bladder
capacity, relaxed bladder
ƒ High High resistance urethra resistance urethra Urgency / Urge UI
ƒ Small capacity, overactive Small capacity, overactive bladder (OAB)
bladder (OAB)
Bladder
Bladder
Urethra
Urethra
Stress UI
Mixed
ƒ Low Low resistance urethra
resistance urethra
ƒ Small capacity, hyperactive bladder
Small capacity, hyperactive bladder
ƒ Low Low resistance urethra Low resistance urethra resistance urethra
Bladder
Urethra
Bladder
Urethra
Lower Urinary Tract Symptoms (LUTS)
St
Storage
V idi
Voiding
P t i t iti
Postmicturition
Urgency
Hesitancy
Terminal dribble
Frequency
Poor flow
Postvoid dribble
Nocturia
Intermittency
Sense of
incomplete emptying
Urgency
incontinence
Straining
Stress incontinence
Dysuria
Neurologic Control of the Bladder
Neurologic Control of the Bladder
» Voiding initiation and coordination
g
○ Primary center in brainstem (Pons)
○ Secondary center in sacral spinal cord
Secondary center in sacral spinal cord
» Brain (cortex)—inhibits voiding
» Spinal cord—nerve pathway
Spinal cord nerve pathway
» Pelvic nerves—carry final messages to the bl
bladder
» Input from pelvis and legs to spinal cord inhibits voiding
Nerve Innervation of the Bladder
Nerve Innervation of the Bladder
» Two main branches of nervous system (NS)
y
( )
○ Central NS (CNS)
– Brain Brain
– Spinal cord
○ Peripheral NS h l
– Autonomic (involuntary) NS – Somatic (voluntary) NS
Control of the Detrusor
Control of the Detrusor
» Brain
○ Exerts net inhibitory effect ○ Brain stem is the coordinating center
Brain stem is the coordinating center
– Higher cerebral areas modulate “social continence” (determination of when & where bladder elimination should occur))
Nerve Innervation of the Bladder
Nerve Innervation of the Bladder
» Parasympathetic
y p
NS (Emptying Phase):
( py g
)
○ Contracts Detrusor muscle
○ Relaxes internal urethral sphincter
R l
i t
l
th l hi t
» Sympathetic
y p
NS (Storage Phase):
(
g
)
○ Relaxes Detrusor muscle
○ Contracts internal urethral sphincter
Contracts internal urethral sphincter
Pontine
Mi t iti
Micturition
Centre
bladder full
‐
right time
p
and place
S2‐‐4 in S2
4 in cauda
cauda equina
pelvic & pudendal ns Pontine
Mi t iti
Micturition
Centre
S2‐‐4 in S2
4 in cauda
cauda equina
pelvic & pudendal ns Neurogenic Bladder (NGB)
Neurogenic Bladder (NGB)
» NGB Dysfunction
NGB Dysfunction
○ Abnormality in storage or voiding function of the bladder as a result of a neurologic
the bladder as a result of a neurologic disturbance
○ Must be confirmed by objective evidence of a M b
fi
d b bj i
id
f
nervous system disorder
Summary of Definitions
Summary of Definitions
» Detrusor areflexia
○ Complete inability of the detrusor to empty
due to a lower motor neuron lesion
(eg, sacral cord or peripheral nerves). » Detrusor hyperreflexia
yp
○ Overactive bladder symptoms due to a suprapontine
upper motor neuron neurologic disorder. ○ External sphincter functions normally. ○ Detrusor muscle and the external sphincter function p
in synergy (in coordination). Summary of Definitions (continued)
Summary of Definitions ( ti
d)
» Detrusor Sphincter Dyssynergia
p
y y g ((DSD) )
○ Both the detrusor and the sphincter are contracting at the same time; they are in dyssynergy (lack of coordination). ○ Paradoxically, the patient does not completely
emptying the bladder.
Summary of Definitions (continued)
Summary of Definitions ( ti
d)
» Detrusor overactivity
○ Overactive bladder symptoms without neurologic impairment. ○ External sphincter functions normally, in synergy. E t
l hi t f ti
ll i
» Overactive bladder ○ Symptoms of urinary urgency, with or without urge incontinence, usually associated with frequency
and nocturia
and nocturia. ○ Cause may be neurologic or nonneurologic. Urinary Retention (UR)
Urinary Retention (UR)
» Definition
○ Inability of the urinary bladder to empty. ○ Cause may be neurologic
C
b
l i
– Damage and/or disruption of the central or peripheral pathways involved in the central
i h l th
i
l d i th
t l
control of the lower urinary tract
○ Cause may be nonneurologic.
Ca se ma be nonne rologic
– Bladder obstruction
Urinary Retention (UR)
Urinary Retention (UR)
» Can be either Acute or Chronic
» Criteria –
○ Post‐void residual (PVR) volume > 75 to 100 cc
Post‐void residual (PVR) volume > 75 to 100 cc
○ Elderly patients > 150 to 200 cc ○ Should be based on 2 separate readings
Should be based on 2 separate readings
» Prevalence rises with age
○ Men‐Secondary to increasing risk of enlargement
d
k f l
of prostate gland
○ Onset of neurologic conditions (e.g. diabetes). O t f
l i
diti
(
di b t )
Types of Urinary Retention Definition
Types of Urinary Retention Definition
» Acute urinary retention (UR)
y
( )
○ Abrupt and complete inability to void
○ Lower abdominal discomfort
L
bd i l di
f t
○ Need immediate and rapid bladder decompression
○ Indwelling catheter used short term
○ Removal of the catheter after a period of time ((“trial w/o catheter” or TWOC)
/
)
Types of Urinary Retention Definition
Types of Urinary Retention Definition
» Chronic urinary retention (UR)
y
( )
○ Ongoing, gradual inability to void
○ Takes months to develop
Takes months to develop
○ Bladder becomes used to being stretched ○ Patients will:
Patients will:
– Adapt to the condition
– Void through abdominal straining
g
g
– May not be aware of it.
○ Severe UR can expand the bladder to 2 to 3 liters
○ Intermittent catheterization used long‐term
Symptoms
»
»
»
»
»
»
»
»
»
»
Difficulty starting to urinate
Diffi l f ll
Difficulty fully emptying the bladder
i
h bl dd
Weak dribble or stream of urine
L
Loss of small amounts of urine during the day
f
ll
t f i d i th d
Inability to feel when bladder is full
Increased abdominal pressure
Increased abdominal pressure
Lack of urge to urinate
Strained efforts to push urine out of the bladder
Strained efforts to push urine out of the bladder
Frequent urination
Nocturia (waking up >2 times at night to urinate)
(waking up >2 times at night to urinate)
Common Neurologic Conditions Associated with NGB
Associated with NGB
Congenital and
Perinatal Lesions
Perinatal Lesions
Cerebral palsy
Acquired, Stable Conditions
Stroke, Head injury
Hereditary spastic paraparesis, Spinal paraparesis
, Spinal dysraphism**
dysraphism
Trauma
Multiple sclerosis*, Multiple sclerosis*, Spondylosis
Spondylosis
with myelopathy
Sacral Spinal Sacral Spinal p
Spinal Spinal dysraphism
p
dysraphism,
y p
,
Cord
Sacral agenesis,
Ano‐‐rectal Ano
rectal anomaly
anomaly
Conus injury
j y
Tumour
Subsacral
Cauda equina injury, Tumour, Peripheral neuropathy Pelvic nerve injury
Pelvic nerve injury (e g diabetic)
(e.g.
Brain and Brainstem Suprasacral
Spinal Cord Spinal dysraphism, , Spinal dysraphism
Familial dysautonomia
Familial dysautonomia
Familial Acquired, Progressive Conditions
Multiple sclerosis,* Parkinson’s disease, Dementia, Multiple System Atrophy*
» Categorisation of neurological lesions according to time of onset, clinical course and CNS location, with example conditions. » *Conditions
Conditions that can arise in more than one region of the CNS.
that can arise in more than one region of the CNS.
Incidence of Bladder Dysfunction
Incidence of Bladder Dysfunction
» Spinal Cord Injury
p
j y
70%–80%
%
%
» Multiple Sclerosis
50%–80%
» Myelodysplasia
50%–75%
Parkinson’s Disease
» Parkinson’s Disease
15% 35%
15%–35%
» Diabetes
10%–30%
» Cerebrovascular Disease
10%–15%
Spinal Cord Injury
Spinal Cord Injury
Spinal Cord Injury
Spinal Cord Injury (SCI)
p
j y( )
» James A. Garfield, 20th President of the United States, who was shot in the conus medullaris and survived 80 days » During World War 1, During World War 1, ~ 80% of SCI 80% of SCI
patients died from pyelonephritis
» Pyelonephritis “the
the end condition of end condition of
the paraplegic.
Morbidity and Mortality in the Spinal Cord Injury (SCI) Patients
Spinal Cord Injury (SCI) Patients
» By 2006, mortality rate related to diseases of y
,
y
the GU system in SCI persons had decreased to 3.6% » Morbidity and mortality usually occurs due to secondary complications of the SCI rather
secondary complications of the SCI rather than damage to the cord, with the most common and debilitating sequelae being common and debilitating sequelae
being
complications of the renal system
Pearman & England. Handbook of Clinical Neurology New York: North Holland Publishing Company 1976.
Garcia et al. Clin
Garcia et al. Clin Microbiol Infect. 2003;9:780‐
Infect. 2003;9:780‐5.
Spinal Cord Injury (SCI) Patients
p
j y( )
» Dramatic decline in morbidity and mortality Dramatic decline in morbidity and mortality
from urological causes has been a result of:
○ Advent of antibiotics
Ad t f tibi ti
○ Effective bladder management
○ Frequent monitoring of the upper and lower urinary tracts
Acute management
g
of the Neurogenic
g
Bladder is the first aim of the clinician
Mechanism of Injury for Spinal P
Population in the United States
l ti i th U it d St t
Combined Injuries
5.0%
Oth
Other
4.2%
Motorcycle
5.7%
Penetrating
14.1%
14 1%
Fall
21.2%
21 2%
Missing Date
0.8%
Motor Vehicle Accident
32.6%
Pedestrian or
Pedestrian
or
Bike vs. Auto
16.4%
Oliver, et al., (2012) The changing epidemiology of spinal Oliver, et al., (2012) The changing epidemiology of spinal trauma:
trauma:
a 13
a 13‐‐year review from a Level I trauma year review from a Level I trauma centre
centre. Injury. 43(8):pg. 1297.
. Injury. 43(8):pg. 1297.
Neurogenic
Neurogenic Bladder in SCI
Bladder in SCI
» Altered Bladder Function After Injury
j y
○ suprasacral level
– detrusor hyperreflexia, dyssynergia
○ sacral, caudal or peripheral level
l
d l
h ll l
– detrusor areflexia
» Complications of Neurogenic Bladder
Complications of Neurogenic Bladder
○
○
○
○
○
high bladder pressures
incomplete emptying
incomplete emptying
kidney deterioration
UTIs
incontinence
6%
4%
Arm/Hand
Function
8%
Quadraplegics:
Q
p g
22%
Upper Body
/Trunk Strength
48%
Bladder/Bowel/Sex
ual Function
Regaining
g
g Walking
g
22%
Normal Sensation
Elimination Pain
12%
12%
3%
17%
Upper B
U
Body
d
/Trunk Strength
8%
Bladder/Bowel/Sex
ual Function
Paraplegics:
Satisfactory
S
ti f t
chronic
h
i
management is the
highest
g
priority
y
Arm/Hand
Function
Regaining Walking
%
16%
Normal Sensation
Elimination Pain
44%
[Anderson KD. Targeting Recovery: Priorities of the Spinal Cord‐Injured Population J Neurotrauma 2004; 21(10): 1371‐1383]
Multiple Sclerosis (MS)
Multiple Sclerosis and NGB
Multiple Sclerosis and NGB
» If one knows the location and nature of a lesion one can try to predict the type of bladder dysfunction that will occur
y
» In MS, the number, nature, and location of lesions are unknown
lesions are unknown
» Diagnosis and management of NGB in MS is more complex than with other diseases
MS: Pathophysiology
MS: Pathophysiology
» Cervical (~100%), lumbar (~40%),
(
%),
(
%),
sacral (~18%)
○ Corticospinal (lateral), reticulospinal
(lateral) reticulospinal tracts
○ +/‐ sacral and peripheral NS involved also
» Cerebral cortex and midbrain involved in 43‐65%
Multiple Sclerosis and the Bladder
Multiple Sclerosis and the Bladder
» 50‐80% of MS patients have bladder dysfunction p
y
at least once
» Present at presentation in 10%, sometimes the Present at presentation in 10%, sometimes the
only symptom
» Bladder overactivity
Bladder overactivity most common 50‐90%
most common 50 90%
» 30‐65% of these patients have sphincter di
discoordination
di ti
» Bladder areflexia is much less common
Reported Incidence of LUTS
Bowel
39‐73%
Combination
51‐59%
Chronic
Ch
i
Retention
25%
Irritative
Obstructive 37‐99%
Syndrome
34‐79%
Constipation or
Fecal Incontinence
Khan F, Pallant JF, Shea TL, Whishaw M. Multiple sclerosis: prevalence and factors impacting bladder and bowel function in an Australian community cohort. Disabil Rehabil. 2009;31(19):1567‐76.
Cerebrovascular Accident (CVA)
CVA
» Incidence: 160/100, 000
/
,
○ Incidence 65‐74: 6‐12/1000
○ Incidence > 85: 40/1000
I id
> 85 40/1000
» ≈30% recover normal bladder function CVA: Voiding Dysfunction
CVA: Voiding Dysfunction
» Early: retention may occur after acute episode
y
y
p
» Late: when chronic dysfunction occurs:
○ Detrusor overactivity
Detrusor overactivity is MOST COMMON
is MOST COMMON
– Areflexia or ↓ contractility in up to 20%
○ Sphincters synergic
Sphincters synergic
○ Sensation intact
CVA: Incontinence
CVA: Incontinence
» Early: 57%‐83%
y
% %
○ Immobility
○ Impaired consciousness
I
i d
i
» Late (6 mo): 10%‐20%
○ Detrusor overactivity
– Urgency
• Able to suppress: just urge
• Unable to suppress: incontinence
Parkinson’s Disease
Parkinson’s
Parkinson s Disease
Disease
» US prevalence: 100‐150/100
p
/
,000
» Pathology:
○ dopamine deficiency in substantial nigra
d
i d fi i
i
b
i l i
l di
leading to Ach/dopamine imbalance
» Clinical Findings
○ Tremor (“pill rolling”)
( p
g )
○ Bradykinesia
○ Muscular rigidity
Muscular rigidity
Parkinson’s
Parkinson s Disease
Disease
» Voiding dysfunction: 25%‐75%
g y
% %
○ Generally presents after other sx’s of PD
» Of these, about:
○ 50% Irritative
%
Sx
○ 25% Obstructive Sx
○ 25% Both
25% Both
Diabetes
Diabetes Mellitus
Diabetes Mellitus
» 5%‐59% of diabetics report Sx of voiding dysfunction
» Pathophysiology poorly defined
○ Neuropathy 2° derangement of Schwann cell
– Segmental demyelinization/impairment of N conduction
– Most common in middle age/elderly with long‐standing or poorly controlled diabetes mellitus
○ Smooth muscle cell dysfunction
– Na+/K+ ATPase, ○ Other
– altered muscarinic receptors, dec. NO, etc.
Bladder Outlet Obstruction
Bladder Outlet Obstruction
Types of Neurogenic Bladder
U th l Ob t ti
Urethral Obstruction
» Causes
–
–
–
–
–
–
–
Detrusor‐sphincter‐dyssynergia
BPH
Prostatitis
Prostate cancer treatment (e g seeds)
Prostate cancer treatment (e.g.seeds)
Pelvic Organ Prolapse
Urethral stricture
Urethral stricture
Severe constipation/fecal impaction
What Happens If We Don
What Happens If We Don’tt Treat It?
Treat It?
INFECTION
Neurogenic
Detrusor Overactivity
Detrusor
Sphincter
Sphincter Dyssynergia
REFLUX
RENAL
FAILURE
APRN
Nursing
M
Management
t
Basic Principles In Management of Neurogenic Bladder
of Neurogenic Bladder
» Protection of the upper urinary tract by pp
y
y
achieving a low pressure urine storage system » Restoration of (parts of) the lower urinary tract Restoration of (parts of) the lower urinary tract
function by achieving complete bladder emptying → Avoidance of urinary tract infection
emptying →
Avoidance of urinary tract infection
» Improvement of urinary continence
» Improvement of the patient’s quality of life
I
t f th
ti t’
lit f lif
Stöhrer et al. Eur
et al. Eur Urol Update Series 1994;3:170‐
Update Series 1994;3:170‐5.
B
Burns et al. Spine 2001;26 (24 Suppl
Burns et al. Spine 2001;26 (24 l S i 2001 26 (24 Suppl):S129
S
l):S129‐
l)
) S129‐S136. http://www.ncbi.nlm.nih.gov/pubmed/11805620
S136 h //
bi l
ih
/ b d/11805620
Rickwood AM. AM. Semin
Semin Pediatr Surg 2002 May;11(2):108
2002 May;11(2):108‐‐19. http://www.ncbi.nlm.nih.gov/pubmed/11973763
Castro‐‐Diaz et al. Surgery for the neuropathic patient. In: Incontinence, 2nd Castro
Diaz et al. Surgery for the neuropathic patient. In: Incontinence, 2nd edn
edn. Abrams P, . Abrams P, Khoury
Khoury S, Wein A, eds. Plymouth: Health Publication, 2002; pp. 865‐‐891. Publication, 2002; pp. 865
Physical Examination Abdomen
Physical Examination ‐
» Palpation reveals a mid‐line
p
mass extending upward
from the suprapubic
p p
area.
(e.g. enlarged bladder)
» Percussion (dull sound, representing fluid)
Percussion (dull sound, representing fluid)
of the suprapubic areas ○ Dullness of the bladder to the level of the umbilicus Dullness of the bladder to the level of the umbilicus
indicates at least 500 mL of urine in the bladder
○ Bladders containing 1,000mL or more extend well Bladders containing 1,000mL or more extend well
above the umbilicus.
Physical Examination Neurologic Physical Examination ‐
Neurologic
» Gait disorders » Numbness tingling and /or weakness, particularly in a stocking and glove distribution
particularly in a stocking and glove distribution » Diminished or increased deep tendon reflex's » Babinski or Hoffman's » Anal Anal "wink"
wink » Bulbocavernosus reflexes Other
Factors
Other Factors
»
»
»
»
»
»
Concomitant conditions
Overall disability
Manual dexterity
Manual dexterity
Cognitive deficit
Living situation
Caregiver status
g
NGB T t
NGB Treatment
t
Treatment for Neurogenic Bladder
Treatment for Neurogenic Bladder
» FAILURE TO EMPTY
○ Behavioral modification,
○
○
○
○
○
○
○
i.e., pelvic floor exercises
Intermittent
Intermittent catheterization
Botulinum toxin A injection into the sphincter
Suprapubic catheter
I d lli
Indwelling catheter
th t
Sphincterotomy
Urethral stent
Urethral stent
Urinary diversion
» FAILURE TO STORE
○ Lifestyle modifications,
○
○
○
○
i.e., diet and fluid intake, timed voiding
timed voiding
Antimuscarinics/Beta 3 Adrenergics
Botulinum toxin A injections into the detrusor
Indwelling catheter
Indwelling catheter
Reconstruction
Treatments Treatments
» Voiding Maneuvers
g
» Intermittent Catheterization (IC)
» Drug Therapy
Voiding Maneuvers
T h i
Techniques to Stimulate Complete Bladder Emptying Si l
C
l
Bl dd E
i
1. A "trigger" can initiate a bladder contraction.
gg
○ Common method is called "suprapubic tapping“
– Drumming the abdomen overlying the bladder rapidly
7 or 8 times, stop 3 seconds, and repeat. – Application of rhythmic tapping to produce summation effect on the tension receptors in the bladder wall and
effect on the tension receptors in the bladder wall and activation of the reflex arc via the afferent discharges ○ Other trigger mechanisms include: Other trigger mechanisms include:
– Pulling pubic hairs
– Stroking abdomen or inner thigh – Digital anal stimulation. Voiding Maneuvers (continued)
Voiding Maneuvers 2. Double Voiding g
○ Involves urinating twice during each trip to the bathroom to reduce residual urine volumes. ○ Instruct patient to
– Urinate
– Remain on the toilet or stand up
– Attempt to urinate again after a rest period
of several minutes.
Voiding Maneuvers (continued)
Voiding Maneuvers 3. Crede Maneuvers ○ Mean of direct manual compression to empty an atonic or flaccid bladder
– Press firmly with one hand (or both hands) directly into the abdomen over s the bladder ○ Aims to ↑ intravesical pressure to enable/facilitate bladder emptying ○ Can facilitate urination if sphincter
mechanism is not in spasm
Intermittent Catheterization (IC)
Intermittent Catheterization (IC)
Safest bladder management to prevent upper and lower urinary tract complications including:
○ Hydronephrosis
○ Renal calculi
○ Bladder calculi
○ Vesicoureteral reflux
IC Complications
p
• Infection:
○ Bacteriuria
○ Urinary tract infections
○ Chronic pyelonephritis ‐ rare
• Urethral Damage (men)
Urethral Damage (men)
○ Urethritis
○ Urethral stricture ○ Creation of a false passage C ti
f f l
• Epididymitis
• Bladder stones • Pain
• Hematuria
• Bladder stones Intermittent Self‐
Intermittent Self‐
Intermittent Self
Self‐Catheterization (ISC)
Catheterization (ISC)
» Ideal/Successful Patient ○ Unobstructed urethra
U b
d
h
○ Good vision
○ Good perineal
p
hygiene
yg
○ Compliant – motivated patient or caregiver
○ Ability to perform other self‐care (e.g. dressing, transfers)
» Problem Patient ○ Obesity/large abdominal girth
Ob it /l
bd i l i th
○ Woman with abductor spasms
Oral Pharmacologic Agents
for the Treatment of NGB
f th T t
t f NGB
Drug Class
Estrogen Derivatives
» Conjugated estrogen (
Conjugated estrogen (Transvaginal
Transvaginal))
Anticholinergic
» Propantheline bromide
» Dicyclomine hydrochloride
Antimuscarinic
» Solifenacin succinate
» Darifenacin
» Oxybutynin chloride » Hyoscyamine sulfate
» Tolterodine L‐tartrate
» Trospium chloride
» Fesoterodine
Beta3 Adrenergic agonist
» Mirabegron
Tricyclic Antidepressants*
» Imipramine hydrochloride
*Off‐‐label
*Off
» Amitriptyline hydrochloride
Behavioral Interventions
S h d l d
Scheduled
Education
Toileting
Lifestyle
Interventions
Programs
NGB
Pelvic Floor Muscle
Exercises With Biofeedback
Therapy
Pelvic floor
Bladder Training
electrical stimulation
Urge Suppression
PTNS
Strategies
Botulinum Toxin ‐
Toxin Bladder
» Intravesical/Intraprostatic/Intraurethral
/
p
/
therapy
py
» Injected directly into organ
(muscle,
suburothelium or
urothelium)
(muscle, suburothelium
or urothelium)
» Approved fro NGB in MS & SCI, OAB
Dos
e?
Botulinum Toxin: Bladder IInjection Technique j ti T h i
Injection Map
Injection Map