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

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

History

UK survey GPRD Increased 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

Bladder management Life Quality of life

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

Knowledge

Innervation lower urinary tract S2 S3 S4 T10-L1

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

Neuropathy lower urinary tract S2 S3 S4 T10-L1

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

Importance of intravesical pressure Do not forget !

Pressure development during filling

Pressure development during filling Pressure development during voiding

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

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

2. Urologic Diagnosis Urodynamic function Status upper tract Other complications

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

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

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

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

Main types of LUT neuropathy in SCL

Further diagnostics Ultrasound Endoscopy

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

Conservative treatment neurogenic bladder

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

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

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

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

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

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.

Less urethral complications Suprapubic catheter Less urethral complications

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.

Surgery neurogenic bladder

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

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

Surgery decrease outlet resistance TUI sphincter Intraurethral stents Botulinum Toxin

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

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

Diversion Acceptable treatment in selected cases

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

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

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.

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.

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

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

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

Thanks for listening