1. Management of the Neurogenic Bladder in Late Childhood to Adulthood
Rosalia Misseri, MD
James Whitcomb Riley Hospital for Children
Indiana University School of Medicine Indianapolis, Indiana
Hadley Wood, MD
Glickman Urological and Kidney Institute
Cleveland Clinic Cleveland, Ohio

2. Overview What is transitional urology?
When is it appropriate to consider transition?
How to transition urological care
Neurogenic bladder
protecting kidney function
managing bladder function

3. Growing Up Children with spina bifida grow up to become adults
Preparation for adulthood is essential
Encourage them to look after themselves and take part in normal family life…from the beginning
50% to 75% become adults
Survival improved in the Western world due to Major surgical and medical advancements
Some Drs and health care systems forget this
With few exceptions few things get better with age
Going from childhood to adulthood is a transition
Little research ha sfocused on the consequences of growing up with spia bifida
Things not dealt with in childhood will be much more difficult to deal with as an adult 3

4. Growing Up How do things change? Urologically Sexually
50% to 75% become adults
Survival improved in the Western world due to Major surgical and medical advancements
Some Drs and health care systems forget this
With few exceptions few things get better with age
Going from childhood to adulthood is a transition
Little research ha sfocused on the consequences of growing up with spia bifida
Things not dealt with in childhood will be much more difficult to deal with as an adult 4

5. Growing Up
CHALLENGE
Transition of care for this growing population

6. Growing Up Renal failure remains the most common cause of death
Pulmonary and cardiac disease are becoming more common
Increased risk of atherosclerosis
Cardenas, DD et al . Sexual function in adolescents and young adults with sb. Archives of phys med rehabil 2008, 89:31-5
Sexual function is a complex activity that involves specific physiological responses that may be altered in an individual with cns impairment such as sb.
Renal failure at all ages is the most common cause of death
Risk of failure is strongly related to the sensory level
Rare at sensory levels at or below L4 and common at or above T10 (HUNT GM, Lewin WS, 1973
Atherosclerosis even without obesity Rendeli, C, castorina m, 2004 6

7. Finding a urologist who understands your problems!!!

8. TRANSITION

9. Transitional urology
Subspecialty care with a focus on adolescents and adults with congenital anomalies or chronic urological issues
Requires specialty expertise in:
anatomy/congenital anomalies
reconstructive urology
knowledge of long-term effects of prior interventions/operations

10. Transitional Urology
May also need support of social work or financial services to help patients navigate medical coverage issues
Also functions as patient advocate/liaison for other subspecialists within urology and other specialties (cardiology, neurology, etc.)

11. Issues addressed at initial visit
Current urological problems/needs
Current living situation, work/school, and goals for the future
Key players (care-providers, significant others, dependents) in patient’s life
Quality of life concerns from parents/care-givers and patient

12. Issues addressed at initial visit
Detailed review of prior surgeries/interventions, complications, and signed medical release for records
Assessment of current status of the following:
Renal function Stone history
Bladder management Sexuality issues/goals
Infection history Fertility issues/goals
Fecal continence history/goals
Urinary continence history/goals

13. When is it appropriate to consider transition?
Age alone is not a good criteria
Patient, care-provider, pediatric urologist mutually agree that the urological issues are more “adult” in nature
When the current urologist is uncomfortable or not capable of addressing the relevant issues

14. When is it appropriate to consider transition?
When a urologist with subspecialty interest/expertise in transitional urological care can be identified
The patient has a change of life (moving, new job, marriage, etc.) where it is reasonable to change medical care venue

15. How to transition urological care
Discuss with key players
(family, care-givers, urologist)
Gather records (and keep a copy) of all prior interventions, radiological and lab tests.
Request a referral, consult SBA or other local resources for guidance

16. How to transition urological care
Talk with other care providers (cardiologist, neurologist, etc.)
Think about and prioritize relevant urological goals/issues
Bring someone with you who knows your history
Request last appointment slot of the day or double-slot

17. NEUROGENIC BLADDER
Urinary problem in which the bladder does not empty properly due to a neurological condition such as spina bifida

18. NEUROGENIC BLADDER:
Primary Goals for Management
The primary goal of the urologist is always to maintain and preserve renal function

19. What do the kidneys do? Filter the blood = eliminate waste
Maintain acid-base balance
Impacts growth & stone development
Produce some hormones
Impacts growth & puberty
Help regulate blood pressure
Regulate fluid balance by making urine

20. What can go wrong with the kidneys?
Infections
Hydronephrosis
Stones
Loss of function

21. What can go wrong with the kidneys?
Infections
Prophylaxis
Prevention
Treatment
Treat when have symptoms
Ped nephr :
Uti in children with sb
No agreement, individualized

22. What can go wrong with the kidneys?
Hydronephrosis
Persistent
New
Changes in bladder dynamics
Poor catheterization technique
Blockage

23. What can go wrong with the kidneys?
Stones
Decreased mobility
Calcium metabolism
Electrolyte abnormalities
Anatomical abnormalities
Ped nephr :
Uti in children with sb
No agreement, individualized

24. What can go wrong with the kidneys?
LOSS OF FUNCTION
Renal failure was the most common cause of death in spina bifida patients in past
Renal failure still occurs in spina bifida
It can be prevented!
At all ages: renal failure can be a cause of death from SB
Prior to CIC it was THE PRIMARY cause of death at all ages
Risk of renal failure is related to sensory level
Rarely seen with levels below L4
More common with levels above T10
Renal failure can occur with even minor neural tube defects such as SB occulta
In one study of SBO in 55 patients*
43% had urological sx’s
All eventually became incontinent
8 developed renal failure*Silveri, et al Ped Surg Intern, 1997 24

25. x Personal Adherence/compliance to medical regimen Regular monitoring
Drink water
Prevent infection
Cath or void as directed
(TAKING CARE OF YOUR BLADDER TAKES CARE OF YOUR KIDNEYS!!)
Take your medicine
See your doctor
Check renal function, check bladder function
Treat infections
Personal
Diet: ↓protein ???
Fluid management
Hygiene: prevent infection
Adherence/compliance to medical regimen
Void or cath as directed
Take medications as directed
Regular monitoring
Annual check-ups
Renal function studies
X-rays as needed
+/- UDS
Aggressive interventions as needed
Treat infections quickly and completely 25

26. Goals for the adolescent/adult patient with neurogenic bladder
Prevent problems before they arise
Identify which factors can be improved and which cannot
Identify the risks of each line of treatment
Balancing the risks and benefits of any treatment

27. Bladder function Stores urine Any type of UI may be present: Bladder:
Overactive (urge incontinence)
Poorly compliant
Underactive (overflow)
(Normal)
Outlet (urethra, sphincter)
Overactive
Fixed, non-relaxing (obstructing)
Dyssynergic (obstructing)
Underactive (stress)
Open bladder neck 27

28. Bladder Outlet Stores urine Any type of UI may be present: Bladder:
Overactive (urge incontinence)
Poorly compliant
Underactive (overflow)
(Normal)
Outlet (urethra, sphincter)
Overactive
Fixed, non-relaxing (obstructing)
Dyssynergic (obstructing)
Underactive (stress)
Open bladder neck
OUTLET 28

29. Bladder function
May worsen due to outlet resistance or a tethered cord
Outlet resistance increases
Not always a positive
Bladder function does not improve spontaneously
Bladder function may worsen
Incontinence
Renal failure
It may APPEAR to be better….but actually be worse !!!!!!
Prostate growth
?continence improved in some
Worry about increased DLPP and renal failure
Difficulty cathing
Renal deterioration, when present, is largely SILENT
Must have regular monitoring
Renal function, imaging
Blood pressure monitoring 29

30. Bladder function: tethered cord
25% patients age 2-8
Usually combination of new-onset neurological, orthopedic and urological problems
10% present with isolated new urologic problem
(Herman et al., 1993; Tarcan et al., 2001; Tarcan et al., 2006b; Abrahamsson et al., 2007; Bowman et al., 2009)
10% present with isolated new urologic problem (Herman et al., 1993)

31. Bladder function: tethered cord
Urologic symptoms:
new onset of upper tract dilatation (hydronephrosis)
vesicoureteral reflux
urinary incontinence
urinary tract infection
Treatment: cord release (surgery)
(Herman et al., 1993; Tarcan et al., 2001; Tarcan et al., 2006b; Abrahamsson et al., 2007; Bowman et al., 2009)
10% present with isolated new urologic problem (Herman et al., 1993)

32. Bladder function: neurogenic bladder
A bladder that stores urine at pressures that are too high to keep the kidneys from deterioration
Requires consistent management
Intermittent catheterization
Anticholinergic medications
Often both
Usually first line therapy 32

33. Bladder function: neurogenic bladder
RISKS
End stage renal damage
Social stigma and complications of incontinence
GOALS
Maintain healthy kidneys
Continence 33

34. Bladder function: incontinence
Causes:
Decreased outlet resistance (sphincter)
Bladder irritation (stone/infection)
Increased bladder storage pressure (neurogenic bladder)
Overflow
It has been shown that behavioral therapy alone can improve the symptoms of OAB
However, it is often difficult to achieve high compliance with behavioral therapies, and optimal success is dependent on how intense the program is and, in many cases, also requires a high input of caregiver time
Studies have shown that the best outcomes are achieved with a combination of pharmacologic and behavioral therapy
Pads
Clamps
Plugs
Pessaries
Catheters:
Indwelling: Urethral or Suprapubic (abdominal)
External (Texas or condom catheters)
SKIN CARE !!!!!!!!!!!!!! 34

35. Bladder function: incontinence
With aging, other risk factors can increase the risk for incontinence:
Surgery of the prostate (♂)
Vaginal childbirth (♀)
Weight gain
It has been shown that behavioral therapy alone can improve the symptoms of OAB
However, it is often difficult to achieve high compliance with behavioral therapies, and optimal success is dependent on how intense the program is and, in many cases, also requires a high input of caregiver time
Studies have shown that the best outcomes are achieved with a combination of pharmacologic and behavioral therapy
Pads
Clamps
Plugs
Pessaries
Catheters:
Indwelling: Urethral or Suprapubic (abdominal)
External (Texas or condom catheters)
SKIN CARE !!!!!!!!!!!!!! 35

36. Treatments of incontinence
Behavioral: timed voiding, catheterization, avoid bladder irritants in diet
Pharmacologic: anticholinergics
Surgical:
Decrease storage pressure
Botox, bladder augmentation
Increase outlet resistance
sling, artificial sphincter
Combination
It has been shown that behavioral therapy alone can improve the symptoms of OAB
However, it is often difficult to achieve high compliance with behavioral therapies, and optimal success is dependent on how intense the program is and, in many cases, also requires a high input of caregiver time
Studies have shown that the best outcomes are achieved with a combination of pharmacologic and behavioral therapy
Pads
Clamps
Plugs
Pessaries
Catheters:
Indwelling: Urethral or Suprapubic (abdominal)
External (Texas or condom catheters)
SKIN CARE !!!!!!!!!!!!!! 36

37. Treatment of neurogenic bladder: Intermittent Catheterization
LONG TERM RISKS
STRICTURE
0-20%
TRAUMA
EPIDIDYMITIS
ACCESS
SUPPLIES
Why:
Reduction of pressure by intermittent drainage of bladder
Continence
Avoidance of UTI, hydronephrosis
Clean…..not sterile (usually)
Difficult cases:
Coude tipped, Olive tipped, etc.
Single use closed systems
Hydrophilic catheters
Other issues:
Size of catheter (French)
Type of catheter (silicone, etc.)
Schedule of catheterization
Cleaning of catheters
Changing catheters 37

38. Treatment of neurogenic bladder: Anticholinergics
SIDE EFFECTS
Dry mouth
Constipation
Headache
COST
Only oxybutinin is generic

39. Anticholinergic Medications: Treatment Considerations
COST!!
Frequency of dosing
Characteristics to limit sleepiness
Limitation of other side effects (constipation)
Antispasmotic effect (intravesical oxybutinin)
Drug interactions
Delivery mechanism: oral versus topical/transdermal/intravesical
QD dosing- tolterodine, oxybutinin, solifenacin, darifenacin
Quarternary amine structure- trospium
M3 (solifenacin) or M3>M2 (darifenacin)
Functionally uroselective (tolterodine) :
Most are p450 metabolized, exception trospium
Oral/extended release best tolerated- lowest peak serum concentrations, hepatic metabolism to active metabolites is minimized
Topical/transdermal/intravesical formulations- bypass first pass metabolism, limit GI sfx

40. Treatment of neurogenic bladder: Surgery
Botox injection
Endoscopic procedure/outpatient
Onset within 2 weeks after treatment
Effect lasts ~ 6 months
Side effects rare and minor (<10%)
Efficacy:
Reduction from baseline incontinence: 40%-80%
65%-87% of patients became completely continent (between caths) after Botox
Main issue is cost/insurance coverage…

41. Treatment of neurogenic bladder: Surgery
Make the bladder larger/lower pressure
Bladder augmentation
Make the outlet tighter
Sling, artificial sphincter
Despite attempts with conservative/medical tx:
Elevated intravesical storage pressure (“Hostile” bladder)
Leakage of urine between catheterizations
Inability or unwillingness to catheterize urethra
Obesity, contractures, mobility issues with ageing
Need to divert urine (i.e., pressure ulcer)
Other:
Catheter complications
Recurrent UTI’s (depending on the cause)
+/- damaging reflux
Reconstruction of bladder or urethra or both
Broadly categorized as either:
Continent:
Store urinary safely until a periodic drainage can be effected (usually 4-5 x per day)
Incontinent:
Conduct urine immediately out of the body into an appliance
While avoiding:
UTI, renal deterioration, odor, skin and stoma problems
While minimizing:
short and long term costs, inconvenience, metabolic disturbances, stones, reoperation rate, and maintain body image 41

42. Treatment of neurogenic bladder: Surgery
Risks with increasing age
Risks with increasing obesity
Infection
Cardiovascular status
Pulmonary status
Deep venous thrombosis

43. Treatment of neurogenic bladder: Surgery
Significant periods of immobility
Difficulty positioning
Difficulty accessing abdomen
Potential for fracture
Increased incidence of Latex allergies
Decline in respiratory reserve
Worsening scoliosis
Difficult
Worsening kyphoscoliosis
Rotational deformity 43

44. Treatment of neurogenic bladder: Surgery
How do we decide what to do?
Urodynamics
Gives us an idea of bladder storage pressure
> 40 mmHg is dangerous
Gives us an idea of bladder capacity
Low capacity means frequent voiding/ISC
Gives us an idea of outlet resistance
Tells us whether sling/sphincter can reduce leakage

45. Treatment of neurogenic bladder: Surgery

46. Treatment of neurogenic bladder: Surgery Catheterizable channel
Monti-Yang
Mitrofanoff
Appendicovesicostomy

47. Treatment of neurogenic bladder:
Surgery
Augmentation: Long-term concerns
Catheterization
Stricture
Continence
Tumors

48. Stricture Continence Positioning Treatment of neurogenic bladder:
Catheterization
LONG-TERM CONCERNS
Stricture
Continence
Positioning

49. Treatment of neurogenic bladder:
Bladder augmentation
LONG-TERM CONCERNS
Calculi
Vitamin B12 deficiency
Rupture
Malignancy

50. Treatment of neurogenic bladder: Tumors
Chronic urinary tract infections
Smoking
Inflammation
Stones
Indwelling catheter
Augmentation cystoplasty
Estimated risk 1.2% to 3.8%
Hypothesized etiologic factors
Chronic indwelling foley in sc injury for more than 10 yrs = 10%
Reports of ca in pts on cic (Khoury JM and Freeman JA, bjui, 1999; Yaqoob M , McClelland P et al Lancet 1991)
The role of bladder aug as a risk factor for TCC remains controversial 50

51. Treatment of neurogenic bladder:
Catheterizations, Bladder Augmentation & Tumors
Seek medical assistance
Hematuria
Recurrent UTIs
Difficulties catheterizing
Surveillance cystoscopy
Cytology
Biopsy
LIFELONG UROLOGIC FOLLOW-UP
THESE RECOMMENDATIONS ARE CONTROVERSIAL, SOME CLAIM THAT IT IS NOT COST EFFECTIVE TO DO SO. Our Rec cysto at 10 yrs from augment 51

52. Treatment of neurogenic bladder: outlet procedures

53. Treatment of neurogenic bladder: outlet procedures
May change storage pressures and jeopardize kidney function
Requires postoperative urodynamics/monitoring
Sphincter is not a good choice if the patient requires catheterization (prior augmentation)
Device failure
Sphincter % (10 years)
Sling- depends
Device infection
Sphincter- 1%

54. Summary Bladder function changes
Goals/priorities of the patient change
Risks of interventions change
Critical to have a urologist who:
Understands the issues
Can counsel you on realistic expectations
Has surgical and medical expertise in this field
AND IS WITH YOU FOR THE LONG HAUL!