1. Neurogenic bladder in patients with spinal cord lesion
2007
JJ Wyndaele
MD DBMSci PhD FEBU FISCOS

2. Prevalence neurogenic bladder in spinal lesion 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

3. History

4. UK survey GPRD
Increased risk renal failure paraplegia versus general population
x 7.5
x 8
x 5.9
x 3.5
Lawrenson, Wyndaele, Vlachonikolas, Farmer, Glickman Neuroepidemiology 2001; 20:

5. Bladder management
Life
Quality of life

6. Management neuro-urology after spinal cord lesion
Prevent deterioration of the kidneys
= permit to survive
Prevention of incontinence and infection
= permit a good life

7. Knowledge

8. Innervation lower urinary tractS2 S3 S4
T10-L1

9. Neurogenic Actions Sym PSym Som Bladder - + Bladder neck Extern US (?)
Pelvic floor

10. Neuropathy lower urinary tractS2 S3 S4
T10-L1

11. function of lower tract
Do not forget !
Status upper tract
depends greatly on
function of lower tract

12. Importance of intravesical pressure
Do not forget !

13. Pressure development during filling

14. Pressure development during filling
Pressure development during voiding

15. SCL Urinary Function Spinal shock bladder
Diagnosis type neurogenic bladder
Treatment - rehabilitation
Follow-up

16. Avoid overdistention and infection
1. Spinal shock bladder
Bladder drainage
intermittent catheterization
suprapubic catheter
indwelling transurethral catheter
Avoid overdistention and infection

17. 2. Urologic Diagnosis Urodynamic function Status upper tract
Other complications

18. 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

19. Combination of these data permits a fairly accurate diagnosis of completeness, detrusor function and sphincter function in up to 80 %

20. Clinical observation is very important
Spontaneous voiding
Leakage when moving
Smelly urine, Fever and other signs of infection
Calculi evacuated
et al

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

22. Main types of LUT neuropathy in SCL

23. Further diagnostics
Ultrasound
Endoscopy

24. Expectations of management
Rehab team
Kidneys safe
No complications
Continent
Affordable
Patient
Continent
No complications
Affordable
Kidneys safe

25. Conservative treatment neurogenic bladder

26. Conservative treatment overview
Behavioural therapy B.1 Behavioural methods Toiletting assistance
B.2 Triggered reflex voiding B.3 Bladder expression (Crede and Valsalva manouvre)
Catheters C.1 Intermittent catheterisation C.2 Indwelling catheterisation C.3 Condom catheter and external appliances
Pharmacotherapy

27. Behavioural methods Scheduled voiding Consecutive voids
Increased interval
Drinking habits
Toilet accessibility
Patient’s mobility
Keeping voiding diary

28. Triggered voiding and Valsalva-Crede voiding
Prove first urodynamically safe:
Basically dangerous methods.

29. Intermittent catheterisation
First choice of treatment
Proper education and teaching necessary.
CIC

30. Pharmacological treatment
Decrease bladder overactivity
Anti bacterial
Peroral, Intravesical instillation, transdermal, transrectal

31. 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.

32. Less urethral complications
Suprapubic catheter
Less urethral complications

33. 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.

34. Surgery neurogenic bladder

35. Surgery to increase detrusor contractility + abolish reflex activity
SARS + Dorsal Rhizotomy

36. Possible alternatives to avoid rhizotomy: under research
Selective anodal block
Cryotherapy deafferentation
SPARSI (anterior + posterior rooths)

37. Surgery decrease outlet resistance
TUI sphincter
Intraurethral stents
Botulinum Toxin

38. Surgery to lower detrusor contractility – intravesical pressure
Botulinum Toxin in detrusor
Enterocystoplasty
Autoaugmentation

39. Surgery to increase sphincter resistance
Artificial urinary sphincter
Sling procedures
Resorbable or non –resorbable bulking agents

40. Diversion
Acceptable treatment in selected cases

41. Future ? Restoring function by nerve transplants? Cell therapy ?
Stem cell therapy ?

42. 4. Follow-up Lifelong every 1 – 2 years Must include
Imaging UT / function UT
Urine
Blood
(Urodynamics)

43. 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.

44. 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.

45. 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

46. 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

47. 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

48. Thanks for listening