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

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Presentation on theme: "1 Neurogenic bladder in patients with spinal cord lesion JJ Wyndaele MD DBMSci PhD FEBU FISCOS 2007."— Presentation transcript:

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

2 2 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

3 3 History

4 4 UK survey GPRD Increased risk renal failure paraplegia versus general populationIncreased risk renal failure paraplegia versus general population 1994 x 7.5 1995 x 8 1996 x 5.9 1997 x 3.5 Lawrenson, Wyndaele, Vlachonikolas, Farmer, Glickman Neuroepidemiology 2001; 20: 138-143

5 5 Bladder management LifeLife Quality of lifeQuality of life

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

7 7

8 8 S2 S3 S4 Innervation lower urinary tract T10- L1

9 9 Neurogenic Actions SymPSymSom Bladder-+ Bladder neck +- Extern US (?) (?)(?)+ Pelvic floor +

10 10 S2 S3 S4 Neuropathy lower urinary tract T10- L1

11 11 Status upper tract depends greatly on depends greatly on function of lower tract function of lower tract

12 12 Importance of of intravesical intravesical pressure pressure

13 13 Pressure development during fillingPressure development during filling

14 14 Pressure development during fillingPressure development during filling Pressure development during voidingPressure development during voiding

15 15 SCL Urinary Function 1.Spinal shock bladder 2.Diagnosis type neurogenic bladder 3.Treatment - rehabilitation 4.Follow-up

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

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

18 18 Diagnosis Most tests as used in non neurogenic: History, clinical examination and neurourologic testing, urine test, renal functionMost 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 19 Combination of these data permits a fairly accurate diagnosis of completeness, detrusor function and sphincter function in up to 80 %

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

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

22 22 Main types of LUT neuropathy in SCL

23 23 Further diagnostics UltrasoundUltrasound EndoscopyEndoscopy

24 24 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

25 25 Conservative treatment neurogenic bladder

26 26 Conservative treatment overview Behavioural therapy B.1 Behavioural methods Toiletting assistanceBehavioural 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 appliancesCatheters C.1 Intermittent catheterisation C.2 Indwelling catheterisation C.3 Condom catheter and external appliances PharmacotherapyPharmacotherapy

27 27 Behavioural methods Scheduled voidingScheduled voiding Consecutive voidsConsecutive voids Increased intervalIncreased interval Drinking habitsDrinking habits Toilet accessibilityToilet accessibility Patient’s mobilityPatient’s mobility Keeping voiding diaryKeeping voiding diary

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

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

30 30 Pharmacological treatment Decrease bladder overactivityDecrease bladder overactivity Anti bacterialAnti bacterial Peroral, Intravesical instillation, transdermal, transrectalPeroral, Intravesical instillation, transdermal, transrectal

31 31 Indwelling catheters Short-term ID during the acute phaseShort-term ID during the acute phase Transurethral ID not safe for long-term use in neuropathic patientsTransurethral 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.Bladder screening for bladder cancer is mandatory especially in those with ID/SC more than 5-10 years.

32 32 Suprapubic catheter Less urethral complications

33 33 Condom Catheter Long-term use does not increase the risk of UTILong-term use does not increase the risk of UTI Complications less if good hygiene care, frequently change CC and low bladder pressures.Complications less if good hygiene care, frequently change CC and low bladder pressures.

34 34 Surgery neurogenic bladder

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

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

37 37 Surgery decrease outlet resistance TUI sphincterTUI sphincter Intraurethral stentsIntraurethral stents Botulinum ToxinBotulinum Toxin

38 38 Surgery to lower detrusor contractility – intravesical pressure Botulinum Toxin in detrusorBotulinum Toxin in detrusor EnterocystoplastyEnterocystoplasty AutoaugmentationAutoaugmentation

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

40 40 Diversion Acceptable treatment in selected casesAcceptable treatment in selected cases

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

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

43 43 Quality of life (meta- analysis) SCI significantly lower in all subscales compared with normative populationSCI significantly lower in all subscales compared with normative population Neurogenic pain, spasticity, and neurogenic bladder and bowel problems give lower QL scores.Neurogenic pain, spasticity, and neurogenic bladder and bowel problems give lower QL scores.

44 44 Quality of life in primary caregivers (meta-analysis) significantly lower compared to age-matched healthy population based controlssignificantly 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.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 45 Causes for readmission “The leading cause of rehospitalization are diseases of the genitourinary system, including urinary tract infections”“The leading cause of rehospitalization are diseases of the genitourinary system, including urinary tract infections” Cardenas et al Arch Physic Med Rehab 2004Cardenas et al Arch Physic Med Rehab 2004

46 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 47 Conclusions Urinary problems less dangerous for life expectancy than some decades agoUrinary problems less dangerous for life expectancy than some decades ago Follow up life longFollow up life long Urinary problems still very much influencing quality of lifeUrinary problems still very much influencing quality of life Bladder management cross- disciplinary workBladder management cross- disciplinary work Patient is centralPatient is central Do not forget relativesDo not forget relatives

48 48 Thanks for listening


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